MEDICARE: BRYAN L GODDARD MD

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	207Q00000X	Family Medicine Physician	2008004918	MO
2	207Q00000X	Family Medicine Physician	150318	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6754C1	OTHER	NY	EMPIRE BC
2	4228179	OTHER	NY	AETNA
3	101115000088	OTHER	NY	FIDELIS
4	PRC110032213	OTHER	NY	CDPHP
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	305800	OTHER	NY	SENIOR WHOLE HEALTH
7	642981	OTHER	NY	GHI/HMO

General Provider Information

NPI Number	:	1780678169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN L GODDARD MD

Provider Business Mailing Address
First Line	:	711 TROY SCHENECTADY RD STE 203
Second Line	:
City	:	LATHAM
State	:	NY
Zip	:	12110-2461
Country	:	US
Telephone Number	:	518-782-3700
Fax Number	:	518-782-3799

Provider Business Practice Location Address
First Line	:	2524 ROUTE 9W
Second Line	:
City	:	RAVENA
State	:	NY
Zip	:	12143-2804
Country	:	US
Telephone Number	:	518-756-7390
Fax Number	:	518-756-8030

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

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	01/18/2018

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Directions to “ BRYAN L GODDARD MD” Practice Location

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