MEDICARE: DR. RONALD S GOLDBERG MD PHD

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	174400000X	Specialist	MD00017869	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659378941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD S GOLDBERG MD PHD

Provider Business Mailing Address
First Line	:	4525 3RD AVE SE
Second Line	:	STE 200
City	:	LACEY
State	:	WA
Zip	:	98503-1010
Country	:	US
Telephone Number	:	360-412-8909
Fax Number	:	360-412-8954

Provider Business Practice Location Address
First Line	:	4525 3RD AVE SE
Second Line	:	STE 200
City	:	LACEY
State	:	WA
Zip	:	98503-1010
Country	:	US
Telephone Number	:	360-412-8909
Fax Number	:	360-412-8954

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

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	07/08/2007

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