Basic Information
| Provider Information | |||||||||
| NPI: | 1033120944 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDBERG | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 MACARTHUR BLVD | ||||||||
| Address2: | ATTN ANESTHESIA | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198367040 | ||||||||
| FaxNumber: | 2195131127 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 MACARTHUR BLVD | ||||||||
| Address2: | ATTN ANESTHESIA | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198361600 | ||||||||
| FaxNumber: | 2195131127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 05/19/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01044641A | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 000000494496 | 01 | IN | ANTHEM BCBS | OTHER | 30558703 | 05 | IN | MEDICAID | 200858430 | 05 | IN | MEDICAID |