Healthcare Provider Details

I. General information

NPI: 1083419451
Provider Name (Legal Business Name): ABIGAIL GOLDBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2025
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1839 N BOUVIER ST
PHILADELPHIA PA
19121-3383
US

IV. Provider business mailing address

1839 N BOUVIER ST
PHILADELPHIA PA
19121-3383
US

V. Phone/Fax

Practice location:
  • Phone: 614-937-2982
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number1068761
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: