Provider Demographics
NPI:1073595518
Name:GOLDBERG, RICHARD (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 MARYLAND RD
Mailing Address - Street 2:SUITE 20
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1700
Mailing Address - Country:US
Mailing Address - Phone:215-830-8700
Mailing Address - Fax:215-830-8715
Practice Address - Street 1:2400 MARYLAND RD
Practice Address - Street 2:SUITE 20
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1700
Practice Address - Country:US
Practice Address - Phone:215-830-8700
Practice Address - Fax:215-830-8715
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006254L208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE40977Medicare UPIN
PA601652Medicare ID - Type UnspecifiedMEDICARE NUMBER