Provider Demographics
NPI:1356431720
Name:GOLDBERG, RICHARD STUART (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:STUART
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:PO BOX 5230
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-5230
Mailing Address - Country:US
Mailing Address - Phone:708-814-6600
Mailing Address - Fax:630-920-9095
Practice Address - Street 1:8311 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2529
Practice Address - Country:US
Practice Address - Phone:708-814-6600
Practice Address - Fax:708-209-2283
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360568682084A0401X, 2084F0202X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363148505-60611-01Medicaid
ILD14534Medicare UPIN
IL363148505-60611-01Medicaid