Healthcare Provider Details

I. General information

NPI: 1184832487
Provider Name (Legal Business Name): ALLEN I GOLDBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1018 W DIVERSEY PKWY #2
CHICAGO IL
60614-1317
US

IV. Provider business mailing address

1018 W DIVERSEY PKWY #2
CHICAGO IL
60614-1317
US

V. Phone/Fax

Practice location:
  • Phone: 773-248-8025
  • Fax: 773-883-1018
Mailing address:
  • Phone: 773-248-8025
  • Fax: 773-883-1018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-057657
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: