Provider Demographics
NPI:1104317999
Name:GOODMAN, KALIE MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:KALIE
Middle Name:MARIE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:48 CENTENNIAL WAY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4662
Practice Address - Country:US
Practice Address - Phone:864-522-8000
Practice Address - Fax:864-522-8005
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13271767-1205208600000X, 208C00000X
SCLL52459208600000X
SC92979208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty