=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952463200
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK GOLDSTEIN DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 512 FASHION AVE 1404A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10018-4603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-768-7979
-----------------------------------------------------
Fax | 212-768-1223
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 316 THE PROMENADE
-----------------------------------------------------
City | EDGEWATER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07020-2109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-533-3197
-----------------------------------------------------
Fax | 212-768-1223
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | X009637-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------