Provider Demographics
NPI:1619310703
Name:GOOLSBY, CHARLES (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:GOOLSBY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27W251 VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 E HURON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:312-926-6948
Practice Address - Fax:312-926-0560
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital