=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114230943
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILIE GOODYEAR MDCM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2010
-----------------------------------------------------
Last Update Date | 07/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 DELAWARE ST SE MMC 493
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55455-0341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-625-4400
-----------------------------------------------------
Fax | 612-626-3119
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 420 DELAWARE ST SE MMC 493
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55455-0341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-625-4400
-----------------------------------------------------
Fax | 612-626-3119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC2000X
-----------------------------------------------------
Taxonomy Name | Children's Hospital
-----------------------------------------------------
License Number | 52783
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------