Healthcare Provider Details

I. General information

NPI: 1245340207
Provider Name (Legal Business Name): GOOD WILL MEDICAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5115 BEACH CHANNEL DR
FAR ROCKAWAY NY
11691-1042
US

IV. Provider business mailing address

158 W 27TH ST 11TH FLOOR SOUTH
NEW YORK NY
10001-6216
US

V. Phone/Fax

Practice location:
  • Phone: 212-563-2497
  • Fax: 212-563-0605
Mailing address:
  • Phone: 212-563-2497
  • Fax: 212-563-0605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER A GALVIN
Title or Position: DIRECTOR
Credential: M.D.
Phone: 212-563-2497