MEDICARE: DR. RYAN WILLIAM GOODELL

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1932625316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RYAN WILLIAM GOODELL

Provider Business Mailing Address
First Line	:	30 FARRAND ST APT 530
Second Line	:
City	:	BLOOMFIELD
State	:	NJ
Zip	:	07003-4439
Country	:	US
Telephone Number	:	585-322-5434
Fax Number	:	973-200-2252

Provider Business Practice Location Address
First Line	:	561 BLOOMFIELD AVE
Second Line	:
City	:	VERONA
State	:	NJ
Zip	:	07044-1818
Country	:	US
Telephone Number	:	973-744-6279
Fax Number	:

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

Provider Enumeration Date	:	08/17/2017
Last Update Date	:	03/15/2022

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