MEDICARE: DR. ALLEN I GOLDBERG M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	036-057657	IL

General Provider Information

NPI Number	:	1184832487
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALLEN I GOLDBERG M.D.

Provider Business Mailing Address
First Line	:	1018 W DIVERSEY PKWY
Second Line	:	#2
City	:	CHICAGO
State	:	IL
Zip	:	60614-1317
Country	:	US
Telephone Number	:	773-248-8025
Fax Number	:	773-883-1018

Provider Business Practice Location Address
First Line	:	1018 W DIVERSEY PKWY
Second Line	:	#2
City	:	CHICAGO
State	:	IL
Zip	:	60614-1317
Country	:	US
Telephone Number	:	773-248-8025
Fax Number	:	773-883-1018

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	07/08/2007

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