MEDICARE: GOLDEN OAK MEDICAL LLC

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	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1720543721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN OAK MEDICAL LLC

Provider Business Mailing Address
First Line	:	334 HILLSIDE DR S
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11040-2720
Country	:	US
Telephone Number	:	718-598-6808
Fax Number	:	770-502-6792

Provider Business Practice Location Address
First Line	:	334 HILLSIDE DR S
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11040-2720
Country	:	US
Telephone Number	:	718-598-6808
Fax Number	:	770-502-6792

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	KANDICE KING
Credential	:
Telephone Number	:	847-228-3303

Provider Enumeration Date	:	02/04/2019
Last Update Date	:	06/26/2020

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