1649286832 NPI number — BRUCE S GOLDBERG

Table of content: BRUCE S GOLDBERG (NPI 1649286832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649286832 NPI number — BRUCE S GOLDBERG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDBERG
Provider First Name:
BRUCE
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1649286832
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 241148
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68124-5148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-968-4574
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1314 RIDGEWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68124-1315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-968-4574
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2006

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: 183500000X , with the licence number:  9780 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 183500000X , with the licence number: 16516 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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