Basic Information
| Provider Information | |||||||||
| NPI: | 1386611564 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | BRIAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7301 OHMS LANE | ||||||||
| Address2: | SUITE 650 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528359880 | ||||||||
| FaxNumber: | 9528571554 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 E NICOLLET BLVD | ||||||||
| Address2: | FAIRVIEW RIDGES HOSPITAL | ||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528922021 | ||||||||
| FaxNumber: | 9528922670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 207P00000X | 45985 | MN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 303674000 | 05 | MN | MEDICAID | 45985 | 01 | MN | MEDICAL LICENSE | OTHER |