MEDICARE: GOLAN INTEGRATED PHYSICAL MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204C00000X	Sports Medicine (Neuromusculoskeletal Medicine) Physician	7091	NV

General Provider Information

NPI Number	:	1417479189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLAN INTEGRATED PHYSICAL MEDICINE

Provider Business Mailing Address
First Line	:	PO BOX 561564
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80256-1564
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3061 S MARYLAND PKWY STE 201
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89109-6227
Country	:	US
Telephone Number	:	702-396-4993
Fax Number	:	702-478-9594

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID GOLAN
Credential	:	MD
Telephone Number	:	480-213-8448

Provider Enumeration Date	:	07/13/2017
Last Update Date	:	07/21/2022

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