1578561452 NPI number — MRS. MERYL STACEY GOLDSTEIN MPT

Table of content: MRS. MERYL STACEY GOLDSTEIN MPT (NPI 1578561452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578561452 NPI number — MRS. MERYL STACEY GOLDSTEIN MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDSTEIN
Provider First Name:
MERYL
Provider Middle Name:
STACEY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GELLER
Provider Other First Name:
MERYL
Provider Other Middle Name:
STACEY
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578561452
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 BAINBRIDGE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19147-1568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-629-3837
Provider Business Mailing Address Fax Number:
215-629-5531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1888 ROUTE 70 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHERRY HILL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08003-2178
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-424-7524
Provider Business Practice Location Address Fax Number:
856-424-7599
Provider Enumeration Date:
07/13/2005

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: 225100000X , with the licence number:  40QA01068200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: PT015033 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 12267951 . This is a "MULTIPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2009310000 . This is a "BC/BS HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1316251 . This is a "BC/BS PPO" identifier . This identifiers is of the category "OTHER".