Healthcare Provider Details

I. General information

NPI: 1861480022
Provider Name (Legal Business Name): JESSE GOLDMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

IV. Provider business mailing address

1601 CHERRY ST SUITE 11511
PHILADELPHIA PA
19102-1320
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-3381
  • Fax: 215-707-4148
Mailing address:
  • Phone: 215-255-7822
  • Fax: 215-255-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD050104L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: