MEDICARE: MR. MATTHEW ALAN GODDARD

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	222Z00000X	Orthotist

General Provider Information

NPI Number	:	1306981345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW ALAN GODDARD

Provider Business Mailing Address
First Line	:	2740 N PINE GROVE AVE APT 13C
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-6103
Country	:	US
Telephone Number	:	773-327-3228
Fax Number	:	773-327-1054

Provider Business Practice Location Address
First Line	:	2515 N CLARK ST STE 802
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2730
Country	:	US
Telephone Number	:	773-327-3228
Fax Number	:	773-327-1054

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

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	07/08/2007

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