Healthcare Provider Details

I. General information

NPI: 1144239591
Provider Name (Legal Business Name): SCOTT JASON GOLDSTEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 N LAKE SHORE DR STE 123
CHICAGO IL
60611-4546
US

IV. Provider business mailing address

1242 S FEDERAL ST D
CHICAGO IL
60605-3388
US

V. Phone/Fax

Practice location:
  • Phone: 312-642-5515
  • Fax: 312-642-0753
Mailing address:
  • Phone: 312-663-6030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: