Provider Demographics
NPI:1821063496
Name:GOLDSTEIN, GREGORY T (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:T
Last Name:GOLDSTEIN
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 1:1638 W SURF ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3599
Mailing Address - Country:US
Mailing Address - Phone:312-890-3999
Mailing Address - Fax:847-919-3849
Practice Address - Street 1:1638 W SURF ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3599
Practice Address - Country:US
Practice Address - Phone:312-890-3999
Practice Address - Fax:847-919-3849
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361048552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104855Medicaid
3001384006OtherRR MC
CN0576OtherGROUP #
ILPTAN IL 1739OtherMRI OF CHICAGO, LLC
IL1615479OtherBCBS
H50670Medicare UPIN
IL920170Medicare ID - Type Unspecified
IL1615479OtherBCBS