1417412958 NPI number — GOLYAN MEDICAL ASSOCIATE PC

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 1417412958 NPI number — GOLYAN MEDICAL ASSOCIATE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLYAN MEDICAL ASSOCIATE 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:
1417412958
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
421 E SHORE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGS POINT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11024-2128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-775-8605
Provider Business Mailing Address Fax Number:
866-215-2323

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6902 AUSTIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOREST HILLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11375-4233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-423-6141
Provider Business Practice Location Address Fax Number:
866-215-2323
Provider Enumeration Date:
02/08/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GOLYAN
Authorized Official First Name:
FARAIDOON
Authorized Official Middle Name:
DANIEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
516-423-6141

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01895596 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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