Provider Demographics
NPI:1396932596
Name:HEIDI GOLDBERG MD PA
Entity type:Organization
Organization Name:HEIDI GOLDBERG MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-269-2422
Mailing Address - Street 1:9555 SEMINOLE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-2523
Mailing Address - Country:US
Mailing Address - Phone:813-269-2422
Mailing Address - Fax:813-269-2441
Practice Address - Street 1:9555 SEMINOLE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-2523
Practice Address - Country:US
Practice Address - Phone:813-269-2422
Practice Address - Fax:813-269-2441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0053509207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAH174Medicare PIN