Basic Information
Provider Information | |||||||||
NPI: | 1033237524 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOLDBERG | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | KEITH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 783311 | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191783311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4848844500 | ||||||||
FaxNumber: | 4848840699 | ||||||||
Practice Location | |||||||||
Address1: | 2775 SCHOENERSVILLE RD | ||||||||
Address2: |   | ||||||||
City: | BETHLEHEM | ||||||||
State: | PA | ||||||||
PostalCode: | 180177307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6108618080 | ||||||||
FaxNumber: | 6108070366 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2007 | ||||||||
LastUpdateDate: | 03/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | MD433440 | PA | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 1911317 | 01 |   | AETNA HMO | OTHER | 1327120 | 01 |   | CIGNA HEALTHCARE | OTHER | 2048241 | 01 |   | HIGHMARK BLUE SHIELD | OTHER | 1572581 | 01 |   | GATEWAY HEALTH PLAN | OTHER | 50078679 | 01 |   | KEYSTONE HEALTH PLAN CENTRAL | OTHER | 3528272000 | 01 |   | AMERIHEALTH | OTHER | 3528272000 | 01 |   | KEYSTONE HEALTH PLAN EAST | OTHER | 117838 | 01 |   | GEISINGER HEALTH PLAN | OTHER | 2912575 | 01 |   | UNITED HEALTHCARE | OTHER | 823127 | 01 |   | FIRST PRIORITY HEALTH | OTHER | 50079517 | 01 |   | CAPITAL BLUE CROSS | OTHER | 3528272000 | 01 |   | INDEPENDENCE BLUE CROSS | OTHER | 9552149 | 01 |   | AETNA PPO | OTHER |