1568565190 NPI number — BRUCE A GOLDBERG MD

Table of content: BRUCE A GOLDBERG MD (NPI 1568565190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568565190 NPI number — BRUCE A GOLDBERG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDBERG
Provider First Name:
BRUCE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1568565190
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
85 CONSTITUTION LN
Provider Second Line Business Mailing Address:
SUITE 200C
Provider Business Mailing Address City Name:
DANVERS
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01923-3694
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-750-3670
Provider Business Mailing Address Fax Number:
978-750-3606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
85 CONSTITUTION LANE
Provider Second Line Business Practice Location Address:
STE 200C LIBERTY TREE PARK
Provider Business Practice Location Address City Name:
DANVERS
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-750-3670
Provider Business Practice Location Address Fax Number:
978-750-3606
Provider Enumeration Date:
09/07/2006

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: 2084P0800X , with the licence number:  46504 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0805X , with the licence number: 46504 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3015149 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: V02758 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 046504 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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