Healthcare Provider Details

I. General information

NPI: 1679712400
Provider Name (Legal Business Name): THOMAS E GOODRICH MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6015 DURAND AVE SUITE 500
MOUNT PLEASANT WI
53406-5089
US

IV. Provider business mailing address

6015 DURAND AVE SUITE 500
MOUNT PLEASANT WI
53406-5089
US

V. Phone/Fax

Practice location:
  • Phone: 262-456-1000
  • Fax: 262-456-1654
Mailing address:
  • Phone: 262-456-1000
  • Fax: 262-456-1654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28720
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number28720
License Number StateWI

VIII. Authorized Official

Name: DR. THOMAS EDWARD GOODRICH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 262-456-1000