Healthcare Provider Details

I. General information

NPI: 1700196698
Provider Name (Legal Business Name): MITCHELL R GOLDSTEIN, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N EDDY ST
SOUTH BEND IN
46617-2920
US

IV. Provider business mailing address

107 N EDDY ST
SOUTH BEND IN
46617-2920
US

V. Phone/Fax

Practice location:
  • Phone: 574-532-0153
  • Fax: 574-246-1634
Mailing address:
  • Phone: 574-532-0153
  • Fax: 574-246-1634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. MITCHELL ROBERT GOLDSTEIN
Title or Position: OWNER
Credential: MD
Phone: 574-532-0153