Basic Information
| Provider Information | |||||||||
| NPI: | 1568410918 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDMAN | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 WALNUT ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | LEMOYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170431168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177610208 | ||||||||
| FaxNumber: | 7177612023 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 UNION DEPOSIT RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171113774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175459666 | ||||||||
| FaxNumber: | 7175451546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 09/17/2009 | ||||||||
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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 | 207R00000X | MD013524E | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0006964800001 | 05 | PA | MEDICAID |