Healthcare Provider Details

I. General information

NPI: 1649251810
Provider Name (Legal Business Name): LARY S GOLDMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30335 W 13 MILE RD SUITE 103
FARMINGTON HILLS MI
48334-2262
US

IV. Provider business mailing address

30335 W 13 MILE RD SUITE 103
FARMINGTON HILLS MI
48334-2262
US

V. Phone/Fax

Practice location:
  • Phone: 248-419-3400
  • Fax: 248-419-3410
Mailing address:
  • Phone: 248-419-3400
  • Fax: 248-419-3410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301045138
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: