Provider Demographics
NPI:1053511394
Name:GOLDSBOROUGH, EDWARD NMN IV (IDC)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:NMN
Last Name:GOLDSBOROUGH
Suffix:IV
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8736 S 50TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-1340
Mailing Address - Country:US
Mailing Address - Phone:847-454-4046
Mailing Address - Fax:
Practice Address - Street 1:3001 A 6TH ST
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088
Practice Address - Country:US
Practice Address - Phone:847-688-4560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman