Mark Goodrich, PAC
Individual provider Active NPI Physician Assistant · Clinton, UT
NPI 1356447882 · NPPES record last updated Oct 13, 2009
Key facts
- NPI
- 1356447882
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physician Assistant 363A00000X
- License
- 2729721206 (UT)
- Practice address
- 1477 North 2000 West
Westside Medical
Clinton, UT 84015 - Phone
- (801) 774-8888
- Fax
- (801) 825-8519
- NPI assigned
- Sep 15, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in UT
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20050609001067 | UT | Practitioner - Physician Assistant | 9133162183 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2729721206 | UT | MD | Physician Assistant |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 2729721206 | UT | Yes |
Addresses
Primary practice location
1477 North 2000 West
Westside Medical
Clinton, UT 84015
Mailing address
1477 North 2000 West
Westside Medical
Clinton, UT 84015
Phone (801) 774-8888
Other providers in Clinton, UT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 13, 2009. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.