Provider Demographics
NPI:1548349988
Name:GOLDENBERG, BRUCE (PT)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:GOLDENBERG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 APACHE CIR
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-1502
Mailing Address - Country:US
Mailing Address - Phone:410-456-3241
Mailing Address - Fax:
Practice Address - Street 1:2504 APACHE CIR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-1502
Practice Address - Country:US
Practice Address - Phone:410-456-3241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21561225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD653CPHOtherMARYLAND PARTICIPATING PR
MD0005262100Medicaid
MDN218OtherBLUECHOICE PROVIDER
MD464SMedicare UPIN