Provider Demographics
NPI:1861480022
Name:GOLDMAN, JESSE (MD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 CHERRY ST
Mailing Address - Street 2:SUITE 11511
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1320
Mailing Address - Country:US
Mailing Address - Phone:215-255-7822
Mailing Address - Fax:215-255-7825
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-3381
Practice Address - Fax:215-707-4148
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD050104L207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014224520007Medicaid
F61300Medicare UPIN
058772Medicare ID - Type Unspecified