Basic Information
| Provider Information | |||||||||
| NPI: | 1871688176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | GREG | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4685 FOREST AVE STE C | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452123359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132467800 | ||||||||
| FaxNumber: | 5132467852 | ||||||||
| Practice Location | |||||||||
| Address1: | 7810 FIVE MILE ROAD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132467000 | ||||||||
| FaxNumber: | 5132462876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 01/21/2015 | ||||||||
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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 | 225100000X | PT008453 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2490782 | 05 | OH | MEDICAID | PT.008435 | 01 | OH | OH LIC | OTHER |