Healthcare Provider Details

I. General information

NPI: 1396764197
Provider Name (Legal Business Name): LARRY E. GOLDSTEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 CHESTNUT STREET SUITE 703
PHILADELPHIA PA
19107-4414
US

IV. Provider business mailing address

833 CHESTNUT STREET SUITE 703
PHILADELPHIA PA
19107-4414
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-1000
  • Fax: 215-923-2275
Mailing address:
  • Phone: 215-955-1000
  • Fax: 215-923-2275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberPAK000141
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD-015799-E
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD015799E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: