Basic Information
| Provider Information | |||||||||
| NPI: | 1336357219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDSTEIN | ||||||||
| FirstName: | ETHAN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2520 S TELEGRAPH RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BLOOMFIELD HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483020285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483359207 | ||||||||
| FaxNumber: | 2483352394 | ||||||||
| Practice Location | |||||||||
| Address1: | 2520 S TELEGRAPH RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BLOOMFIELD HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483020285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483359207 | ||||||||
| FaxNumber: | 2483352394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 01/07/2011 | ||||||||
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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 | 207V00000X | 4301081848 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.