=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174799340
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINNACLE MID-ATLANTIC PAIN MEDICINE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2008
-----------------------------------------------------
Last Update Date | 12/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2010 OLD WEST CHESTER PIKE SUITE 330
-----------------------------------------------------
City | HAVERTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-789-8070
-----------------------------------------------------
Fax | 610-789-9937
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 660024
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75266-0024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-789-8070
-----------------------------------------------------
Fax | 610-789-9937
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | WILLIAM GOLDSTEIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 610-789-8070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------