1205051216 NPI number — TREVOR GOLBOURNE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205051216 NPI number — TREVOR GOLBOURNE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLBOURNE
Provider First Name:
TREVOR
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOLBOURNE
Provider Other First Name:
TREVOR
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1205051216
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
618 POWELLS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTBURY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11590-1321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-445-6128
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 10TH AVE
Provider Second Line Business Practice Location Address:
10G
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10019-1147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-636-3400
Provider Business Practice Location Address Fax Number:
212-636-3296
Provider Enumeration Date:
04/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  005726 , 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)





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