Basic Information
| Provider Information | |||||||||
| NPI: | 1194778878 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDIE | ||||||||
| FirstName: | GAINNEOS | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 783311 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191783311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848844500 | ||||||||
| FaxNumber: | 4848840699 | ||||||||
| Practice Location | |||||||||
| Address1: | 17TH AND CHEW STREETS | ||||||||
| Address2: | GROUND FLOOR | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181057017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109693390 | ||||||||
| FaxNumber: | 6109693393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | M0735 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 87599 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RG0300X | MD447980 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 175370901 | 05 | TX | MEDICAID | 8W8852 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 175370902 | 05 | TX | MEDICAID | 175370903 | 05 | TX | MEDICAID |