MEDICARE: SHLOMIE GOLDBERG P.A.

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	363A00000X	Physician Assistant	009275-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00286373	OTHER	NY	RAILROAD

General Provider Information

NPI Number	:	1609842582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHLOMIE GOLDBERG P.A.

Provider Business Mailing Address
First Line	:	PO BOX 409041
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30384-9041
Country	:	US
Telephone Number	:	800-377-8721
Fax Number	:	304-523-2241

Provider Business Practice Location Address
First Line	:	150 55TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-2559
Country	:	US
Telephone Number	:	718-630-7185
Fax Number	:

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

Provider Enumeration Date	:	02/28/2006
Last Update Date	:	10/24/2007

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