Basic Information
| Provider Information | |||||||||
| NPI: | 1740273523 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | PHILIP | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 W STATE ST | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139012322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077729462 | ||||||||
| FaxNumber: | 6077721223 | ||||||||
| Practice Location | |||||||||
| Address1: | 169 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139054246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077985223 | ||||||||
| FaxNumber: | 6077986187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 146413 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 01416146 | 05 | NY | MEDICAID |