1124103585 NPI number — GOOD WILL MEDICAL PC

Table of content: (NPI 1124103585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124103585 NPI number — GOOD WILL MEDICAL PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOOD WILL MEDICAL PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124103585
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
158 WEST 27TH STREET
Provider Second Line Business Mailing Address:
11 FLOOR SOUTH
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10001-6216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-524-7724
Provider Business Mailing Address Fax Number:
212-543-8201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51 15 BEACH CHANNEL DRIVE
Provider Second Line Business Practice Location Address:
PENINSULA HOSPITAL
Provider Business Practice Location Address City Name:
FAR ROCKAWAY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11691-1074
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-734-2345
Provider Business Practice Location Address Fax Number:
718-734-2808
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAUFER
Authorized Official First Name:
SALLI
Authorized Official Middle Name:
Authorized Official Title or Position:
ATTENDING HOSPITALIST
Authorized Official Telephone Number:
718-734-2345

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  207114 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01809549 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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