Healthcare Provider Details

I. General information

NPI: 1376531400
Provider Name (Legal Business Name): MELVIN J GOLDSTEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 08/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST SUITE 1525
CHICAGO IL
60611-2927
US

IV. Provider business mailing address

PO BOX 388320
CHICAGO IL
60638-8320
US

V. Phone/Fax

Practice location:
  • Phone: 312-337-1556
  • Fax: 312-266-0478
Mailing address:
  • Phone: 773-767-8283
  • Fax: 773-767-8320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036038943
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: