Healthcare Provider Details

I. General information

NPI: 1285835140
Provider Name (Legal Business Name): MICHAEL GOLDBERG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 KEYSTONE AVE STE 206
DREXEL HILL PA
19026
US

IV. Provider business mailing address

2100 KEYSTONE AVE STE 206
DREXEL HILL PA
19026-1124
US

V. Phone/Fax

Practice location:
  • Phone: 610-619-7475
  • Fax:
Mailing address:
  • Phone: 610-619-7475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberQ1614
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberOS018424
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: