Provider Demographics
NPI:1770762643
Name:PHILLIP N. GOLOMB, MD PA
Entity type:Organization
Organization Name:PHILLIP N. GOLOMB, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:NATHAN
Authorized Official - Last Name:GOLOMB
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:334-227-7778
Mailing Address - Street 1:PO BOX 392
Mailing Address - Street 2:
Mailing Address - City:FORT DEPOSIT
Mailing Address - State:AL
Mailing Address - Zip Code:36032-0392
Mailing Address - Country:US
Mailing Address - Phone:334-227-7778
Mailing Address - Fax:
Practice Address - Street 1:19 MILNER STREET
Practice Address - Street 2:
Practice Address - City:FORT DEPOSIT
Practice Address - State:AL
Practice Address - Zip Code:36032
Practice Address - Country:US
Practice Address - Phone:334-227-7778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8601207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty