Provider Demographics
NPI:1851356752
Name:GOLDMAN, LARRY SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:SCOTT
Last Name:GOLDMAN
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 1:1 E ERIE ST STE 355
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2772
Mailing Address - Country:US
Mailing Address - Phone:312-573-0900
Mailing Address - Fax:312-573-1532
Practice Address - Street 1:1 E ERIE ST
Practice Address - Street 2:SUITE 355
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2740
Practice Address - Country:US
Practice Address - Phone:312-573-0900
Practice Address - Fax:312-573-1532
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0591162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059116Medicaid
ILC39112Medicare ID - Type Unspecified