Basic Information
| Provider Information | |||||||||
| NPI: | 1073595633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDSTEIN | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346475299 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 E MEDICAL CENTER DRIVE | ||||||||
| Address2: | 3RD FLOOR CARDIOVASCULAR CENTER | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882871082 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301109030 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 4301109030 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 039468 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RA0001X | 4301109030 | MI | Y |
ID Information
| ID | Type | State | Issuer | Description | 001394684 | 05 | CT | MEDICAID |