Basic Information
| Provider Information | |||||||||
| NPI: | 1679627798 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOUDIE | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | HASBRO 122 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014444612 | ||||||||
| FaxNumber: | 4017938831 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOPPIN ST | ||||||||
| Address2: | CORO BUILDING | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014444612 | ||||||||
| FaxNumber: | 4017938831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 05/03/2011 | ||||||||
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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 | 2080P0202X | C10008082 | DE | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0202X | D0068007 | MD | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0202X | MD429590 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0202X | RI13511 | RI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 109592 | 05 | NJ | MEDICAID | 1679627798 | 05 | VA | MEDICAID | 4110510 | 05 | MD | MEDICAID | 101712508 | 05 | PA | MEDICAID |