Provider Demographics
NPI:1679566178
Name:GOLDBERG, RENWICK N (MD)
Entity Type:Individual
Prefix:
First Name:RENWICK
Middle Name:N
Last Name:GOLDBERG
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 1:8121 ROURK ST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4128
Mailing Address - Country:US
Mailing Address - Phone:843-692-5000
Mailing Address - Fax:843-692-5015
Practice Address - Street 1:8121 ROURK ST
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4128
Practice Address - Country:US
Practice Address - Phone:843-692-5000
Practice Address - Fax:843-692-5015
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12106207RH0003X
NC200100691207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7905743Medicaid
SC121068Medicaid
SCC018822547Medicare PIN
SCC018826037Medicare PIN
NC7905743Medicaid
SC121068Medicaid
NC2021714Medicare PIN
SCC018826527Medicare PIN