Basic Information
| Provider Information | |||||||||
| NPI: | 1871973313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODENOUGH | ||||||||
| FirstName: | ELLIOT | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1427 VINE ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157622530 | ||||||||
| FaxNumber: | 2157622531 | ||||||||
| Practice Location | |||||||||
| Address1: | 1427 VINE ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157622530 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2015 | ||||||||
| LastUpdateDate: | 04/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD460791 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 103315777 | 05 | PA | MEDICAID |