MEDICARE: P C GOODWIN MEDICAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	036076189	IL

General Provider Information

NPI Number	:	1013110444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	P C GOODWIN MEDICAL LLC

Provider Business Mailing Address
First Line	:	18507 INDIE CT
Second Line	:
City	:	HAZEL CREST
State	:	IL
Zip	:	60429-2469
Country	:	US
Telephone Number	:	708-204-0786
Fax Number	:	708-647-9930

Provider Business Practice Location Address
First Line	:	9401 S PULASKI RD
Second Line	:	SUITE 101
City	:	EVERGREEN PARK
State	:	IL
Zip	:	60805-1924
Country	:	US
Telephone Number	:	708-424-2475
Fax Number	:	708-424-2494

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	DR. PAMELA DENISE GOODWIN-COLE
Credential	:	M.D.
Telephone Number	:	708-424-2475

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	09/17/2008

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