Provider Demographics
NPI: | 1366443251 |
---|---|
Name: | GOLL, HAROLD M (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | HAROLD |
Middle Name: | M |
Last Name: | GOLL |
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: | 110 WEST RD |
Mailing Address - Street 2: | SUITE 210 |
Mailing Address - City: | TOWSON |
Mailing Address - State: | MD |
Mailing Address - Zip Code: | 21204-2316 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 410-296-4616 |
Mailing Address - Fax: | 410-337-5068 |
Practice Address - Street 1: | 6701 N CHARLES ST |
Practice Address - Street 2: | |
Practice Address - City: | TOWSON |
Practice Address - State: | MD |
Practice Address - Zip Code: | 21204-6808 |
Practice Address - Country: | US |
Practice Address - Phone: | 410-296-4616 |
Practice Address - Fax: | 410-337-5068 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-08-02 |
Last Update Date: | 2008-07-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MD | D0028695 | 207L00000X, 207LP2900X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | |
No | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MD | D0028695 | Other | STATE LICENSE NUMBER |
MD | 373531100 | Medicaid | |
MD | H506W790 | Medicare PIN | |
MD | C48987 | Medicare UPIN |