Healthcare Provider Details

I. General information

NPI: 1780625509
Provider Name (Legal Business Name): NEIL GOLDBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 RANDOLPH RD STE 208
CHARLOTTE NC
28211-1082
US

IV. Provider business mailing address

3535 RANDOLPH RD STE 208
CHARLOTTE NC
28211-1082
US

V. Phone/Fax

Practice location:
  • Phone: 704-442-9805
  • Fax: 704-405-0868
Mailing address:
  • Phone: 704-442-9805
  • Fax: 704-405-0868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number160284
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number2013-01786
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2013-01786
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2013-01786
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: