1447348826 NPI number — MR. BRADLEY GORDON GOLDBERG M.D.

Table of content: DIANA SINCLAIR (NPI 1801550512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447348826 NPI number — MR. BRADLEY GORDON GOLDBERG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDBERG
Provider First Name:
BRADLEY
Provider Middle Name:
GORDON
Provider Name Prefix Text:
MR.
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:
1447348826
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 CROSS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAZLEHURST
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-384-2500
Provider Business Mailing Address Fax Number:
912-383-6788

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2010 OCILLA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLAS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31533-2230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-384-2500
Provider Business Practice Location Address Fax Number:
912-383-6788
Provider Enumeration Date:
10/10/2006

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: 207V00000X , with the licence number:  040079 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 138903 . This is a "PEACHSTATE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 700394 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000741694D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DH1281 . This is a "RAILROAD MEDICARE - GROUP #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 040079 . This is a "GA LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 040079 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 341191 . This is a "WELLCARE OF GA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: P00726008 . This is a "RAILROAD MEDICARE - PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 11D0941435 . This is a "CLIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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