Provider Demographics
NPI:1386496636
Name:GOODSIDE HEALTH MEDICAL, PLLC
Entity type:Organization
Organization Name:GOODSIDE HEALTH MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-884-5190
Mailing Address - Street 1:1701 RIVER RUN STE 302
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-6547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:209 FAYETTEVILLE ST STE 1-C
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27601-1309
Practice Address - Country:US
Practice Address - Phone:512-884-5190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty