Basic Information
| Provider Information | |||||||||
| NPI: | 1982682449 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDMAN | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38935 ANN ARBOR RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481503354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346320175 | ||||||||
| FaxNumber: | 7346320182 | ||||||||
| Practice Location | |||||||||
| Address1: | 18101 OAKWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481244089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135937000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 10/17/2008 | ||||||||
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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 | 207PE0004X | 4301083561 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 10-4943130 | 05 | MI | MEDICAID | 10-4631198 | 05 | MI | MEDICAID | 10-4631189 | 05 | MI | MEDICAID | 10-4943140 | 05 | MI | MEDICAID | 10-4943159 | 05 | MI | MEDICAID | 0108226702 | 01 | MI | BCBS | OTHER | 10-4631142 | 05 | MI | MEDICAID | 10-4631151 | 05 | MI | MEDICAID | 10-4631160 | 05 | MI | MEDICAID |