Healthcare Provider Details

I. General information

NPI: 1528172236
Provider Name (Legal Business Name): BRUCE D GOLDENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 W LAWRENCE AVE
CHICAGO IL
60630-3404
US

IV. Provider business mailing address

5425 W LAWRENCE AVE
CHICAGO IL
60630-3404
US

V. Phone/Fax

Practice location:
  • Phone: 773-725-7557
  • Fax: 773-794-0138
Mailing address:
  • Phone: 773-725-7557
  • Fax: 773-794-0138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036069603
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number75779
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036069603
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: