MEDICARE: RAYMOND C. GOODMAN JR. M.D.

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	174400000X	Specialist	C4716	AR
2	208600000X	Surgery Physician	C-4716	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	51933	OTHER	AR	AR BLUECROSS BLUESHIELD

General Provider Information

NPI Number	:	1013960442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAYMOND C. GOODMAN JR. M.D.

Provider Business Mailing Address
First Line	:	5401 ELLSWORTH RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-3219
Country	:	US
Telephone Number	:	479-314-4757
Fax Number	:	479-314-4704

Provider Business Practice Location Address
First Line	:	7001 ROGERS AVE
Second Line	:	SUITE 200
City	:	FORT SMITH
State	:	AR
Zip	:	72903-4073
Country	:	US
Telephone Number	:	479-314-4620
Fax Number	:	479-314-4629

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	12/21/2011

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