Healthcare Provider Details

I. General information

NPI: 1932636651
Provider Name (Legal Business Name): SAMUEL GOLDSTEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWTHORNE LN
CHARLOTTE NC
28204-2515
US

IV. Provider business mailing address

3735 GLENLAKE DR STE 250
CHARLOTTE NC
28208-6866
US

V. Phone/Fax

Practice location:
  • Phone: 704-749-5800
  • Fax: 704-626-3237
Mailing address:
  • Phone: 704-749-5800
  • Fax: 704-626-3237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number90143
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2022-00453
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: