MEDICARE: HEIDI GOLDBERG

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	207RG0100X	Gastroenterology Physician	ME0053509	FL

General Provider Information

NPI Number	:	1346353059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEIDI GOLDBERG

Provider Business Mailing Address
First Line	:	15809 PENNINGTON RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33624-1582
Country	:	US
Telephone Number	:	813-960-7841
Fax Number	:

Provider Business Practice Location Address
First Line	:	9555 SEMINOLE BLVD
Second Line	:	STE 201
City	:	SEMINOLE
State	:	FL
Zip	:	33772-2562
Country	:	US
Telephone Number	:	727-393-6881
Fax Number	:

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

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	03/29/2012

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