Basic Information
| Provider Information | |||||||||
| NPI: | 1043865272 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | CHAS | ||||||||
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| Credential: | CAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE STE 401 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645228602 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7 INDEPENDENCE PT STE 300 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645223700 | ||||||||
| FaxNumber: | 8645223705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2019 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367H00000X | 83 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | NAN167 | 05 | SC | MEDICAID |