Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC0200X | Nurse Practitioner - Critical Care Medicine | 209015191 | IL |
NPI | 1518498971 |
---|---|
Provider Name | Mr. Ray Goodwin |
First Address | Chicago, IL 60638-1818 |
Second Address | Chicago, IL 60611-2908 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2017 |
Last Update Date | 27/03/2017 |