Provider Demographics
NPI:1215034673
Name:GOLDBERG, MICHAEL ELLIS (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ELLIS
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 1:710 W 168TH STREET
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-2699
Mailing Address - Country:US
Mailing Address - Phone:212-543-6931
Mailing Address - Fax:212-543-5816
Practice Address - Street 1:710 W 168TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-2699
Practice Address - Country:US
Practice Address - Phone:212-543-6931
Practice Address - Fax:212-543-5816
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225939-12084N0400X
NY225939208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02702298Medicaid
NY02702298Medicaid
NY551N21Medicare ID - Type Unspecified