Basic Information
| Provider Information | |||||||||
| NPI: | 1417913500 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOOD | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 EAST 3RD STREET | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187868364 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 EAST 3RD STREET | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187868364 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 45984 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | 45984 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0407103 | 01 | MEDICA | OTHER | 585241040029 | 01 | PREFERRED ONE | OTHER | 587483100 | 05 | MN | MEDICAID | 68G79G0 | 01 | BCBS | OTHER |