Basic Information
| Provider Information | |||||||||
| NPI: | 1902076938 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BARRY E.GOLDMAN MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 FOREST GLEN RD | ||||||||
| Address2: | |||||||||
| City: | NEW PALTZ | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125612611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452555450 | ||||||||
| FaxNumber: | 8452555854 | ||||||||
| Practice Location | |||||||||
| Address1: | 66 FOREST GLEN RD | ||||||||
| Address2: | |||||||||
| City: | NEW PALTZ | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125612611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452555450 | ||||||||
| FaxNumber: | 8452555854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2008 | ||||||||
| LastUpdateDate: | 03/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | GOLDMAN | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8452555450 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F334111-1 | NY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | 155612-1 | NY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00929144 | 05 | NY | MEDICAID | A63475 | 01 | NY | UPIN | OTHER |