Basic Information
| Provider Information | |||||||||
| NPI: | 1871574301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDBERG | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78866 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532788866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796967150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1340 CHARLES ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611042200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796965888 | ||||||||
| FaxNumber: | 7796965898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 036074317 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.