Basic Information
| Provider Information | |||||||||
| NPI: | 1124172861 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDMAN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 110 S. BEDFORD ROAD | ||||||||
| Address2: | MOUNT KISCO MEDICAL GROUP PC | ||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142411050 | ||||||||
| FaxNumber: | 9142421516 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 N HIGHLAND AVE STE 4 | ||||||||
| Address2: | MOUNT KISCO MEDICAL GROUP PC | ||||||||
| City: | OSSINING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105626301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144682590 | ||||||||
| FaxNumber: | 9144688591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 11/14/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X | 202109 | NY | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy |
ID Information
| ID | Type | State | Issuer | Description | 02252037 | 05 | NY | MEDICAID | P01212360 | 01 | NY | RAILROAD MEDICARE | OTHER |