Provider Demographics
NPI:1962425462
Name:GOLDBERG, RUSSELL S (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:S
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 1:1100 9TH AVE
Mailing Address - Street 2:MS M4-PA
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:206-583-6025
Mailing Address - Fax:206-515-5886
Practice Address - Street 1:13014 120TH AVE NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3015
Practice Address - Country:US
Practice Address - Phone:425-821-8004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020625207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGO7787OtherBLUE SHIELD
WA1109404Medicaid
WAUS0900001OtherAETNA/USHC PCP
WA0039581OtherLABOR & INDUSTRY
WA1109404Medicaid
WA8868688Medicare PIN
WA000181743Medicare PIN
WAUS0900001OtherAETNA/USHC PCP