Basic Information
| Provider Information | |||||||||
| NPI: | 1013995034 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDBERG | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8674 | ||||||||
| Address2: | 1230 E MAIN ST MANKATO CLINIC LTD | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1421 PREMIERE DR | ||||||||
| Address2: | MANKATO CLINIC@ WICKERSHAM CAMPUS | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560016076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 43508 | MN | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 140754 | 01 | MN | UCARE | OTHER | 340019399 | 01 | RR MEDICARE | OTHER | HP34028 | 01 | MN | HEALTH PARTNERS | OTHER | 1808800 | 01 | MN | AMERICAS PPO | OTHER | 1900310 | 01 | MN | MEDICA | OTHER | 0568394 | 01 | IA | MEDICAID | OTHER | 392183200 | 05 | MN | MEDICAID | 47D36GO | 01 | MN | BCBS | OTHER | NA2951028013 | 01 | MN | PREFFERED ONE | OTHER |