Healthcare Provider Details

I. General information

NPI: 1548492226
Provider Name (Legal Business Name): GATEWAY PHYSICIAN GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2009
Last Update Date: 08/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 JORALEMON ST 8TH FLOOR
BROOKLYN NY
11201-4326
US

IV. Provider business mailing address

186 JORALEMON ST 8TH FLOOR
BROOKLYN NY
11201-4326
US

V. Phone/Fax

Practice location:
  • Phone: 718-858-3263
  • Fax:
Mailing address:
  • Phone: 718-858-3263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number185657
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number222545
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number239276
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number096783
License Number StateNY

VIII. Authorized Official

Name: CAROL GODDARD
Title or Position: ADMINISTRATOR
Credential:
Phone: 718-858-3263