Healthcare Provider Details

I. General information

NPI: 1962832485
Provider Name (Legal Business Name): GOLD COAST CARDIOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 NORTHERN BLVD
GREAT NECK NY
11021-4813
US

IV. Provider business mailing address

370 NORTHERN BLVD
GREAT NECK NY
11021-4813
US

V. Phone/Fax

Practice location:
  • Phone: 516-874-0441
  • Fax: 516-874-0441
Mailing address:
  • Phone: 516-874-0441
  • Fax: 516-874-0441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number175571-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE CLANCY
Title or Position: EXECUTIVE ADMINISTRATOR
Credential:
Phone: 631-983-3934