Provider Demographics
NPI:1093817983
Name:GOLDBERG, SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4623 FALLS RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-4914
Mailing Address - Country:US
Mailing Address - Phone:410-366-1980
Mailing Address - Fax:410-366-8530
Practice Address - Street 1:10451 TWIN RIVERS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2388
Practice Address - Country:US
Practice Address - Phone:410-997-3557
Practice Address - Fax:410-964-1791
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00243472084N0600X
MDM179392084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD115468OtherKAISER
MD034197-000OtherMAGELLAN
MDPVPB129834OtherAPS HEALTHCARE
MD347492OtherMAMSI
MDT541-0032OtherCAREFIRST
MD2143757000OtherAMERIHEALTH
MD400491400Medicaid
MD4281365OtherAETNA
MDT541-0032OtherCAREFIRST BCBS - DC