Basic Information
| Provider Information | |||||||||
| NPI: | 1396764197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDSTEIN | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 833 CHESTNUT STREET | ||||||||
| Address2: | SUITE 703 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551000 | ||||||||
| FaxNumber: | 2159232275 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 CHESTNUT STREET | ||||||||
| Address2: | SUITE 703 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551000 | ||||||||
| FaxNumber: | 2159232275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2014 | ||||||||
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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 | 171100000X | PAK000141 | PA | N | Other Service Providers | Acupuncturist | 208800000X | MD-015799-E | PA | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | MD015799E | PA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 7901607 | 05 | NJ | MEDICAID | 000678427 0008 | 05 | PA | MEDICAID |