Basic Information
| Provider Information | |||||||||
| NPI: | 1619976669 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDENBERG | ||||||||
| FirstName: | ILYA | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 TAMARACK RD | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430551183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142971158 | ||||||||
| FaxNumber: | 6142993406 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 TAMARACK RD | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430551183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142971158 | ||||||||
| FaxNumber: | 6142993406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 02/07/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35-081219 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 35-081219 | OH | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 2378896 | 05 | OH | MEDICAID | 7600179 | 01 | OH | UHC | OTHER | 7826564 | 01 | OH | AETNA | OTHER | 000000259749 | 01 | OH | ANTHEM | OTHER | 2097512 | 01 | OH | FIRST HEALTH | OTHER |