=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972715944
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BONNIE MARIE GOODWIN ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 COLLEGE AND MAIN
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43209-7812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-236-6667
-----------------------------------------------------
Fax | 614-236-6178
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5850 MALL VIEW CT
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43231-2927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-901-9306
-----------------------------------------------------
Fax | 614-236-6178
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT000692
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------