Provider Demographics
NPI:1598293409
Name:GOLDBERG, MICHAEL ANATOLEVICH
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANATOLEVICH
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:8051 S EMERSON AVE STE 300
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8630
Practice Address - Country:US
Practice Address - Phone:317-528-8494
Practice Address - Fax:317-528-7118
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01088522A207L00000X, 207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine