Provider Demographics
NPI:1528112679
Name:MINI B GODDARD M D P C
Entity type:Organization
Organization Name:MINI B GODDARD M D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MINI
Authorized Official - Middle Name:B
Authorized Official - Last Name:GODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-479-7800
Mailing Address - Street 1:14600 KING RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-7952
Mailing Address - Country:US
Mailing Address - Phone:734-479-7800
Mailing Address - Fax:734-479-7802
Practice Address - Street 1:14600 KING RD
Practice Address - Street 2:SUITE A
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-7952
Practice Address - Country:US
Practice Address - Phone:734-479-7800
Practice Address - Fax:734-479-7802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064837208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4682722Medicaid
MI2508232231OtherBCBSM
MI2508232231OtherBCBSM
MI0P03090Medicare ID - Type Unspecified