Basic Information
| Provider Information | |||||||||
| NPI: | 1134100738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GODOFSKY | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | ARNOLD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 MEDICAL VILLAGE DR | ||||||||
| Address2: | STE 258 ANETHESIA INTENSIVE CARE CONSULTANTS INC | ||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410175401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593417246 | ||||||||
| FaxNumber: | 8593417867 | ||||||||
| Practice Location | |||||||||
| Address1: | 7500 STATE RD | ||||||||
| Address2: | ANESTHESIA INTENSIVE CARE CONSULTANTS INC | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452552439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593417246 | ||||||||
| FaxNumber: | 8593417867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 09/22/2010 | ||||||||
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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 | 207L00000X | 35 05 3644G | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00000077648 | 01 | ANTHEM | OTHER | 000000012632 | 01 | ANTHEM BLUE SHIELD | OTHER | 10757864 | 01 | CAQH | OTHER | 31 1105593 | 01 | TAX ID | OTHER | 0713240 | 05 | OH | MEDICAID | 200377690 | 05 | IN | MEDICAID | 64027980 | 05 | KY | MEDICAID | 728016 | 01 | BUCKEYE | OTHER | 311585770 1659350494 | 01 | HEALTHNET | OTHER |