MEDICARE: MR. JAY DREW GOODMAN PT, SCS

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	208100000X	Physical Medicine & Rehabilitation Physician	P5645	NC

General Provider Information

NPI Number	:	1023568680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAY DREW GOODMAN PT, SCS

Provider Business Mailing Address
First Line	:	1603 HILLSBOROUGH ST
Second Line	:	WAKEMED AT ALEXANDER YMCA
City	:	RALEIGH
State	:	NC
Zip	:	27605-1638
Country	:	US
Telephone Number	:	919-350-3800
Fax Number	:	919-838-5379

Provider Business Practice Location Address
First Line	:	1603 HILLSBOROUGH ST
Second Line	:	1603 HILLSBOROUGH STREET
City	:	RALEIGH
State	:	NC
Zip	:	27605-1638
Country	:	US
Telephone Number	:	919-350-3800
Fax Number	:	919-838-5379

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

Provider Enumeration Date	:	10/07/2016
Last Update Date	:	10/07/2016

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