1245233261 NPI number — JACK D GOLDSTEIN M.D.1208

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245233261 NPI number — JACK D GOLDSTEIN M.D.1208

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDSTEIN
Provider First Name:
JACK
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.1208
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245233261
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 MASSASOIT AVE
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
E PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02914-2012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-919-5222
Provider Business Mailing Address Fax Number:
401-919-5227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 MASSASOIT AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
E PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02914-2012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-919-5222
Provider Business Practice Location Address Fax Number:
401-919-5227
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  RI8073 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 15131 . This is a "NEIGHBORHOOD HEALTH" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 2432493 . This is a "AETNA US HEALTHCARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 779577 . This is a "TUFTS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 200042974 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 2797369003 . This is a "CIGNA" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 0900689 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 0000022384 . This is a "RI BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 202113 . This is a "RI BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 9020116 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 61829 . This is a "HARVARD PILGRIM HEALTH CA" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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