Basic Information
| Provider Information | |||||||||
| NPI: | 1801853478 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCGOLDRICK | ||||||||
| FirstName: | THOMAS | ||||||||
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| Credential: | PAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 235019 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361235019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342791450 | ||||||||
| FaxNumber: | 3342791660 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 KEMBLE AVE | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315204211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124667000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 04/13/2011 | ||||||||
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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 | 363A00000X | 002040 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 367H00000X | 002040 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100002742A | 05 | GA | MEDICAID |