1952392110 NPI number — GARY R GOLDSTEIN M.D.

Table of content: GARY R GOLDSTEIN M.D. (NPI 1952392110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952392110 NPI number — GARY R GOLDSTEIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDSTEIN
Provider First Name:
GARY
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1952392110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11133 DUNN RD
Provider Second Line Business Mailing Address:
SUITE 2335
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63136-6119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-653-5007
Provider Business Mailing Address Fax Number:
314-653-4149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11133 DUNN RD
Provider Second Line Business Practice Location Address:
SUITE 2335
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63136-6119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-653-5007
Provider Business Practice Location Address Fax Number:
314-653-4149
Provider Enumeration Date:
11/04/2005

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: 207RP1001X , with the licence number:  MOR3M34 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 202810412 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 290007537 . This is a "RAILROAD MEDICARE INDIVIDUAL ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: CE7661 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 290009907 . This is a "RAILROAD MEDICARE PCI ID" identifier . This identifiers is of the category "OTHER".




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