Provider Demographics
NPI:1285733139
Name:GOLDBERG, ROGER P (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:P
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 1:9650 GROSS POINT RD FL 3
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1214
Mailing Address - Country:US
Mailing Address - Phone:224-251-2374
Mailing Address - Fax:847-933-3531
Practice Address - Street 1:9650 GROSS POINT RD FL 3
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076
Practice Address - Country:US
Practice Address - Phone:224-251-2374
Practice Address - Fax:847-933-3531
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099584207VF0040X
IL036-099584207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH05021Medicare UPIN