1720108962 NPI number — STEPHEN ALAN GOLDBERG PH.D.

Table of content: STEPHEN ALAN GOLDBERG PH.D. (NPI 1720108962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720108962 NPI number — STEPHEN ALAN GOLDBERG PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDBERG
Provider First Name:
STEPHEN
Provider Middle Name:
ALAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.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:
1720108962
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:
220 WARING RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKINS PARK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19027-2125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-635-3448
Provider Business Mailing Address Fax Number:
215-635-3448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8018 BUSTLETON AVE.
Provider Second Line Business Practice Location Address:
2ND FLR.
Provider Business Practice Location Address City Name:
PHILA.
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19152-2802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-742-6773
Provider Business Practice Location Address Fax Number:
215-742-5829
Provider Enumeration Date:
03/30/2007

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: 103TC0700X , with the licence number:  PS003906-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: SI02393 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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