Basic Information
Provider Information | |||||||||
NPI: | 1831101278 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOLDMAN | ||||||||
FirstName: | KATHRYN | ||||||||
MiddleName: | ROSENTHAL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROSENTHAL | ||||||||
OtherFirstName: | KATHRYN | ||||||||
OtherMiddleName: | E. | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 131 COVENTRY ST | ||||||||
Address2: | BURGDORF CLINIC - 2ND FLOOR ADMINISTRATION | ||||||||
City: | HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061121548 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8607143690 | ||||||||
FaxNumber: | 8607148683 | ||||||||
Practice Location | |||||||||
Address1: | 131 COVENTRY ST | ||||||||
Address2: | BURGDORF CLINIC - 2ND FLOOR ADMINISTRATION | ||||||||
City: | HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061121548 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8607143690 | ||||||||
FaxNumber: | 8607148683 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/13/2006 | ||||||||
LastUpdateDate: | 07/29/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 025723 | CT | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RI0200X | 025723 | CT | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
ID | Type | State | Issuer | Description | 001257238 | 05 | CT |   | MEDICAID |