Basic Information
| Provider Information | |||||||||
| NPI: | 1033156195 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 432 CHIPPING LN | ||||||||
| Address2: | |||||||||
| City: | CHAGRIN FALLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440236724 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 18901 LAKE SHORE BLVD | ||||||||
| Address2: | |||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441191078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165319000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 05/31/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146D00000X | 34002519G | OH | N | Emergency Medical Service Providers | Personal Emergency Response Attendant | 207P00000X | 34-002519 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 942460636444 | 01 | OH | CARESOURCE | OTHER | P00320003 | 01 | OH | MEDICARE TRAVELERS RR-GA | OTHER | 0440320 | 05 | OH | MEDICAID |