Basic Information
| Provider Information | |||||||||
| NPI: | 1114056389 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOOD MEDICINE A MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 OLD MCCLOUD RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT SHASTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960672796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309265100 | ||||||||
| FaxNumber: | 5309261859 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 OLD MCCLOUD RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT SHASTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960672796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309265100 | ||||||||
| FaxNumber: | 5309261859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 03/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | KOEHLER | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5309265100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | DF3805 | 01 | CA | RAILROAD MEDICARE | OTHER |