Provider Demographics
NPI:1972040319
Name:GOLDBERG, WILLIAM EDWARD
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:EDWARD
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1254 ROBERT STREET SOUTH
Mailing Address - Street 2:1261260 ROBERT STREET SOUTH
Mailing Address - City:WEST ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118
Mailing Address - Country:US
Mailing Address - Phone:651-605-5174
Mailing Address - Fax:
Practice Address - Street 1:1254 ROBERT ST S
Practice Address - Street 2:1260 SOUTH ROBERT STREET
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-2448
Practice Address - Country:US
Practice Address - Phone:651-457-9111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment