Basic Information
Provider Information | |||||||||
NPI: | 1275945909 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOODRUM | ||||||||
FirstName: | ALISHA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STEPHENS | ||||||||
OtherFirstName: | ALISHA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 119 AMBULANCE DR STE 202 | ||||||||
Address2: |   | ||||||||
City: | CARROLLTON | ||||||||
State: | GA | ||||||||
PostalCode: | 301173857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708388710 | ||||||||
FaxNumber: | 7708388563 | ||||||||
Practice Location | |||||||||
Address1: | 101 QUARTZ DR STE 201 | ||||||||
Address2: |   | ||||||||
City: | VILLA RICA | ||||||||
State: | GA | ||||||||
PostalCode: | 301803256 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708123839 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2014 | ||||||||
LastUpdateDate: | 09/28/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0401X | 079346 | GA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine |
No ID Information.