Provider Demographics
NPI:1538244389
Name:GOODMAN, JORDAN (MD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 REMINGTON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:630-914-2469
Practice Address - Street 1:656 N CONVENT ST STE B
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1393
Practice Address - Country:US
Practice Address - Phone:815-936-5186
Practice Address - Fax:815-936-5190
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-081034207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE51718Medicare UPIN