Provider Demographics
NPI:1659330561
Name:GOLDBERG, AVIVA M (MD)
Entity Type:Individual
Prefix:
First Name:AVIVA
Middle Name:M
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2300 CHILDRENS PLAZA
Mailing Address - Street 2:BOX #37
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:773-327-3930
Mailing Address - Fax:773-327-3937
Practice Address - Street 1:2300 N CHILDRENS PLZ
Practice Address - Street 2:BOX #37
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3363
Practice Address - Country:US
Practice Address - Phone:773-327-3930
Practice Address - Fax:773-327-3937
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL2080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I46298Medicare UPIN
ILK23063Medicare ID - Type Unspecified