MEDICARE: GOODSIDE HEALTH MEDICAL, PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207Q00000X	Family Medicine Physician
2	207R00000X	Internal Medicine Physician
3	261Q00000X	Clinic/Center
4	261QM1300X	Multi-Specialty Clinic/Center
5	363A00000X	Physician Assistant
6	363L00000X	Nurse Practitioner
7	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1104555044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOODSIDE HEALTH MEDICAL, PLLC

Provider Business Mailing Address
First Line	:	1701 RIVER RUN STE 302
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6547
Country	:	US
Telephone Number	:	281-203-5006
Fax Number	:

Provider Business Practice Location Address
First Line	:	8601 N BLACK CANYON HWY STE 103-3
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85021-4109
Country	:	US
Telephone Number	:	281-203-5006
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GERARDO REYES
Credential	:	MD
Telephone Number	:	281-203-5006

Provider Enumeration Date	:	06/07/2022
Last Update Date	:	07/01/2022

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