Provider Demographics
NPI:1972704971
Name:JOEL S. GOLDBERG
Entity type:Organization
Organization Name:JOEL S. GOLDBERG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-494-4422
Mailing Address - Street 1:4015 CHICHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BOOTHWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19061
Mailing Address - Country:US
Mailing Address - Phone:610-404-4422
Mailing Address - Fax:
Practice Address - Street 1:4015 CHICHESTER AVE
Practice Address - Street 2:
Practice Address - City:BOOTHWYN
Practice Address - State:PA
Practice Address - Zip Code:19061
Practice Address - Country:US
Practice Address - Phone:610-404-4422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004415L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016128870002Medicaid
PA0016128870002Medicaid