=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376772822
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AARON JAMES GOODRICH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2009
-----------------------------------------------------
Last Update Date | 08/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325TH MEDICAL GROUP 340 MAGNOLIA CIR
-----------------------------------------------------
City | TYNDALL AFB
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32403-5604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-747-5544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 355TH MEDICAL GROUP 4175 S. ALAMO AVE
-----------------------------------------------------
City | DAVIS MONTHAN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85707-4405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-228-2615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25868
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------