Basic Information
Provider Information | |||||||||
NPI: | 1285693648 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOLDBAUM | ||||||||
FirstName: | ABE | ||||||||
MiddleName: | FRANK | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2928 MINOT LN | ||||||||
Address2: |   | ||||||||
City: | WAUKESHA | ||||||||
State: | WI | ||||||||
PostalCode: | 531884451 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2622929091 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2900 W OKLAHOMA AVE | ||||||||
Address2: | SUITE 106 | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532154330 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4146497710 | ||||||||
FaxNumber: | 4146497028 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2006 | ||||||||
LastUpdateDate: | 04/24/2015 | ||||||||
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 | 208100000X | 34054-020 | WI | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 33337700 | 05 | WI |   | MEDICAID |