Healthcare Provider Details

I. General information

NPI: 1750733788
Provider Name (Legal Business Name): GOLD COAST OSTEOPATHIC, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2016
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 N LAKE SHORE DR STE 1040
CHICAGO IL
60611-8718
US

IV. Provider business mailing address

680 N LAKE SHORE DR SUITE 1040
CHICAGO IL
60611-4546
US

V. Phone/Fax

Practice location:
  • Phone: 773-554-6055
  • Fax:
Mailing address:
  • Phone: 773-554-6055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. AIDA BECKERLY
Title or Position: PRESIDENT
Credential:
Phone: 773-554-6055