Basic Information
| Provider Information | |||||||||
| NPI: | 1659690469 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDBERG | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | HARRIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 EAST DERENNE AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126445300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 210 E DERENNE AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314056736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126445300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2010 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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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 | 207X00000X | 075626 | GA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | R2473 | KY | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 4301107949 | MI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 75626 | GA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 003177751A | 05 | GA | MEDICAID |