Basic Information
| Provider Information | |||||||||
| NPI: | 1285615252 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | ROBIN | ||||||||
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| Credential: | MBBCH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 GEORGE STREET | ||||||||
| Address2: | 6TH FLOOR PO BOX 9805 | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065360805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 YORK ST | ||||||||
| Address2: | YNHH SOUTH PAVILION - 2ND FLOOR | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036882433 | ||||||||
| FaxNumber: | 2036889258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 07/07/2008 | ||||||||
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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 | 2085R0202X | 041710 | CT | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 001417105 | 05 | CT | MEDICAID |