=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699112219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUSSELL JAY GOLDSTEIN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2013
-----------------------------------------------------
Last Update Date | 05/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 N 15TH ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19102-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-762-2365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 FRANKLIN VALLEY CIR
-----------------------------------------------------
City | REISTERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21136-5812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-790-0521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | MT204473
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------