Basic Information
| Provider Information | |||||||||
| NPI: | 1912277005 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOOD | ||||||||
| FirstName: | MARY ANN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAHAM | ||||||||
| OtherFirstName: | MARY ANN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2300 N EDWARD ST | ||||||||
| Address2: | GSBLL | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625264163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178762857 | ||||||||
| FaxNumber: | 2178762874 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 N EDWARD ST | ||||||||
| Address2: | SUITE 3200 | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625264163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178763660 | ||||||||
| FaxNumber: | 2178763665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2012 | ||||||||
| LastUpdateDate: | 09/04/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085004263 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.