1528121803 NPI number — DARRYL T GOLDBERG MD PC

Table of content: (NPI 1528121803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528121803 NPI number — DARRYL T GOLDBERG MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DARRYL T GOLDBERG MD PC
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:
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:
1528121803
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27901 WOODWARD AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
BERKLEY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48072
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-398-2525
Provider Business Mailing Address Fax Number:
248-398-9286

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27901 WOODWARD AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
BERKLEY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-398-2525
Provider Business Practice Location Address Fax Number:
248-398-9286
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KALT
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
248-398-2525

Provider Taxonomy Codes

  • Taxonomy code: 156FX1100X , with the licence number:  JK051524 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 180F375320 . This is a "BLUE CROSS BLUE SHIELD OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 180F375320 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3117704 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4237942 . This is a "DETROIT MEDICAL CENTER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 101836 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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