Basic Information
Provider Information | |||||||||
NPI: | 1184670838 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOLDMAN | ||||||||
FirstName: | GEORGE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1649 | ||||||||
Address2: |   | ||||||||
City: | AKRON | ||||||||
State: | OH | ||||||||
PostalCode: | 443091649 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3308648900 | ||||||||
FaxNumber: | 3308698924 | ||||||||
Practice Location | |||||||||
Address1: | 525 E MARKET ST | ||||||||
Address2: |   | ||||||||
City: | AKRON | ||||||||
State: | OH | ||||||||
PostalCode: | 443041619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3303753369 | ||||||||
FaxNumber: | 3303753769 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/25/2006 | ||||||||
LastUpdateDate: | 07/25/2016 | ||||||||
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 | 207P00000X | 35043702 | OH | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 000000138478 | 01 | OH | ANTHEM | OTHER | 930023435 | 01 | OH | RR MEDICARE | OTHER | 61641 | 01 | OH | UNITED HEALTCARE | OTHER | 340714755QQ | 01 | OH | SUMMACARE | OTHER | 341779226003 | 01 | OH | MED MUT OH 2 OF 3 | OTHER | 341779226002 | 01 | OH | MEDICAL MUTUAL OH 1 OF 2 | OTHER | 0427578 | 05 | OH |   | MEDICAID |