Provider Demographics
NPI:1609842582
Name:GOLDBERG, SHLOMIE (PA)
Entity Type:Individual
Prefix:
First Name:SHLOMIE
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:PA
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 409041
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-9041
Mailing Address - Country:US
Mailing Address - Phone:800-377-8721
Mailing Address - Fax:304-523-2241
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2559
Practice Address - Country:US
Practice Address - Phone:718-630-7185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009275-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00286373OtherRAILROAD
NYP00286373OtherRAILROAD
Q13628Medicare UPIN