=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265817837
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARRIS S GOLDENBERG, M.D., S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2015
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2617 GREENWOOD RD
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-7622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-530-2226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2617 GREENWOOD RD
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-7622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-530-2226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. HARRIS S GOLDENBERG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 847-530-2226
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 036043474
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------