Basic Information
| Provider Information | |||||||||
| NPI: | 1659473007 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODEAR | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2671 ELMS PLANTATION BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437976800 | ||||||||
| FaxNumber: | 8437976825 | ||||||||
| Practice Location | |||||||||
| Address1: | 2671 ELMS PLANTATION BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437976800 | ||||||||
| FaxNumber: | 8437976825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 03/03/2008 | ||||||||
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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 | 207RG0100X | 28430 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 284301 | 05 | SC | MEDICAID |