Basic Information
| Provider Information | |||||||||
| NPI: | 1518942952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SINNER | ||||||||
| OtherFirstName: | MONICA | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 320 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564411645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185467000 | ||||||||
| FaxNumber: | 2185454456 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 E MAIN ST | ||||||||
| Address2: | CUYUNA REGIONAL MEDICAL CENTER | ||||||||
| City: | CROSBY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564411645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185467000 | ||||||||
| FaxNumber: | 2185454456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35395 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 236084 | 01 | AMERICA'S PPO | OTHER | E034 | 01 | TRICARE | OTHER | 089005708 | 01 | MEDICARE | OTHER | 0101129 | 01 | MEDICA | OTHER | 2042748 | 01 | AETNA | OTHER | 6T327GO | 01 | BCBS | OTHER | NS1141008752 | 01 | PREFERRED ONE | OTHER | HP24213 | 01 | HEALTHPARTNERS | OTHER | 080057487 | 01 | RR MEDICARE | OTHER | 109778C750 | 01 | UCARE | OTHER | 386308500 | 05 | MN | MEDICAID |