MEDICARE: GOODWOOD PRIMARY CARE CLINIC, 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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1427236660
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOODWOOD PRIMARY CARE CLINIC, LLC

Provider Business Mailing Address
First Line	:	8333 GOODWOOD BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-7744
Country	:	US
Telephone Number	:	225-952-9460
Fax Number	:	225-952-9459

Provider Business Practice Location Address
First Line	:	8333 GOODWOOD BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-7744
Country	:	US
Telephone Number	:	225-952-9460
Fax Number	:	225-952-9459

Authorized Official
Title or Position	:	CEO
Name	:	DR. JONATHAN ROBERTS
Credential	:	PH.D
Telephone Number	:	225-952-9460

Provider Enumeration Date	:	02/08/2008
Last Update Date	:	09/18/2008

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