=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508946187
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOEL JAY GOLDWASSER D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9403 HARFORD RD SUITE 1
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21234-3123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-882-0720
-----------------------------------------------------
Fax | 410-882-6767
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3406 BIRCH HOLLOW RD
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21208-1839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-484-6718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 01148
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------