Provider Demographics
NPI:1124211131
Name:PAUL GOLDSHLACK DO PC
Entity Type:Organization
Organization Name:PAUL GOLDSHLACK DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:GOLDSHLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:517-484-4095
Mailing Address - Street 1:PO BOX 492
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48805-0492
Mailing Address - Country:US
Mailing Address - Phone:517-484-4095
Mailing Address - Fax:
Practice Address - Street 1:1200 E MICHIGAN AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1800
Practice Address - Country:US
Practice Address - Phone:517-484-4095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPG007284207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1153311384OtherBLUE CROSS BLUE SHIELD MI
MI111869414Medicaid
0P27560001Medicare PIN
B45906Medicare UPIN