Provider Demographics
NPI:1376531400
Name:GOLDSTEIN, MELVIN J (MD)
Entity type:Individual
Prefix:
First Name:MELVIN
Middle Name:J
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:PO BOX 388320
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-8320
Mailing Address - Country:US
Mailing Address - Phone:773-767-8283
Mailing Address - Fax:773-767-8320
Practice Address - Street 1:676 N SAINT CLAIR ST
Practice Address - Street 2:SUITE 1525
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-337-1556
Practice Address - Fax:312-266-0478
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036038943207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036038943Medicaid
IL21601042OtherBLUE SHIELD
111528598OtherRAILROAD MEDICARE
IL036038943Medicaid
IL455820Medicare ID - Type Unspecified