MEDICARE: STEPHEN GOLDMAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	036-116174	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	036-116714	OTHER	IL	LICENSE

General Provider Information

NPI Number	:	1477577492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN GOLDMAN M.D.

Provider Business Mailing Address
First Line	:	1850 GATEWAY DR
Second Line	:
City	:	SYCAMORE
State	:	IL
Zip	:	60178-3192
Country	:	US
Telephone Number	:	815-758-8671
Fax Number	:

Provider Business Practice Location Address
First Line	:	1850 GATEWAY DR
Second Line	:
City	:	SYCAMORE
State	:	IL
Zip	:	60178-3192
Country	:	US
Telephone Number	:	815-758-8671
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	09/13/2010

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