Provider Demographics
NPI:1932157104
Name:GOLDSTEIN, IRENE MICHELE (MD)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:MICHELE
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:IRENE
Other - Middle Name:MICHELE
Other - Last Name:HERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4400 W 95TH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2654
Mailing Address - Country:US
Mailing Address - Phone:708-346-4040
Mailing Address - Fax:708-346-3287
Practice Address - Street 1:15614 S HARLEM AVE
Practice Address - Street 2:UNIT F
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4402
Practice Address - Country:US
Practice Address - Phone:855-707-8346
Practice Address - Fax:708-371-4569
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361010142086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101014Medicaid
IL535550016Medicare PIN
IL969780010Medicare PIN
ILP01067840Medicare PIN
ILK06588Medicare UPIN
IL036101014Medicaid