Healthcare Provider Details

I. General information

NPI: 1659330561
Provider Name (Legal Business Name): AVIVA M GOLDBERG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N CHILDRENS PLZ BOX #37
CHICAGO IL
60614-3363
US

IV. Provider business mailing address

2300 CHILDRENS PLAZA BOX #37
CHICAGO IL
60614
US

V. Phone/Fax

Practice location:
  • Phone: 773-327-3930
  • Fax: 773-327-3937
Mailing address:
  • Phone: 773-327-3930
  • Fax: 773-327-3937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: