Basic Information
| Provider Information | |||||||||
| NPI: | 1538112784 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOOD | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3926 KIRKWOOD HWY | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198085110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3029982417 | ||||||||
| FaxNumber: | 3029982485 | ||||||||
| Practice Location | |||||||||
| Address1: | 16490 W 78TH ST | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553464300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3029982417 | ||||||||
| FaxNumber: | 3029982485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 11/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD042587-L | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | C1-0010143 | DE | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001249580 | 05 | PA | MEDICAID |