Individual
EDMOND GODBOUT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
593 EDDY ST, PROVIDENCE, RI 02903-4923
(401) 519-1604
(401) 272-0538
Mailing address
PO BOX 9484, PROVIDENCE, RI 02940-9484
(401) 854-2500
(401) 854-2519
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA00090
RI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01/15/2008
NHPRI
RI
01
—
04/01/2008
BCBSRI
RI
01
—
1710991955
NPI
—
01
—
1962455022
UEMF GROUP NPI
RI
05
—
7008105
—
RI
01
—
939025129
RI MEDICARE GROUP NUMBER
RI
Enumeration date
07/27/2006
Last updated
02/19/2010
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