Healthcare Provider Details

I. General information

NPI: 1710968102
Provider Name (Legal Business Name): STEPHEN BRUCE GOLDBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 RESERVOIR CIR SUITE 202
PIKESVILLE MD
21208-6393
US

IV. Provider business mailing address

2 RESERVOIR CIR SUITE 202
PIKESVILLE MD
21208-6393
US

V. Phone/Fax

Practice location:
  • Phone: 410-653-2647
  • Fax: 410-653-7778
Mailing address:
  • Phone: 410-653-2647
  • Fax: 410-653-7778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberD47001
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number132365
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD218378
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0068985
License Number StateCO
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD60441053
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20638
License Number StateND
# 7
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number132365
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: