Provider Demographics
NPI:1386629707
Name:GOODRICH, MARK F (PT, ATC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:F
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:502-882-9379
Mailing Address - Fax:502-587-5728
Practice Address - Street 1:2121 WILLOW ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-5355
Practice Address - Country:US
Practice Address - Phone:812-882-1141
Practice Address - Fax:812-255-0045
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003266A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000254699OtherBLUE CROSS BLUE SHIELD
INP00050159Medicare UPIN
IN198850AMedicare PIN