1396882544 NPI number — JEROME GOLDSTEIN MD A PROFESSIONAL CORPORATION

Table of content: DIANEY ANDREA GRIJALVA BS (NPI 1568299063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396882544 NPI number — JEROME GOLDSTEIN MD A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEROME GOLDSTEIN MD A PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1396882544
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
909 HYDE ST
Provider Second Line Business Mailing Address:
SUITE # 322
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94109-4822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-673-4600
Provider Business Mailing Address Fax Number:
415-673-9532

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 HYDE ST
Provider Second Line Business Practice Location Address:
SUITE # 322
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94109-4822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-673-4600
Provider Business Practice Location Address Fax Number:
415-673-9532
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDSTEIN
Authorized Official First Name:
JEROME
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
415-673-4600

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G15358 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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