Provider Demographics
NPI:1144313826
Name:STEPHEN M. GOODEN, M.D., P.C.
Entity type:Organization
Organization Name:STEPHEN M. GOODEN, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOODEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-724-5451
Mailing Address - Street 1:1430 B HARPER STREET
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901
Mailing Address - Country:US
Mailing Address - Phone:706-724-5451
Mailing Address - Fax:706-724-9562
Practice Address - Street 1:1430 B HARPER STREET
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901
Practice Address - Country:US
Practice Address - Phone:706-724-5451
Practice Address - Fax:706-724-9562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033972208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00460028AMedicaid
SCGPA822Medicaid
GRP8103Medicare PIN