Healthcare Provider Details

I. General information

NPI: 1962752527
Provider Name (Legal Business Name): GOLD COAST MEDICAL P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 JERICHO TURNPIKE
SYOSSET NY
11791-4513
US

IV. Provider business mailing address

P O BOX 270
MASSAPEQUA PARK NY
11762-0270
US

V. Phone/Fax

Practice location:
  • Phone: 516-584-6400
  • Fax: 516-584-6401
Mailing address:
  • Phone: 631-264-2035
  • Fax: 631-264-1418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number220299
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number StateNY

VIII. Authorized Official

Name: KOSTAS SIDERIDIS
Title or Position: OWNER
Credential: D.O.
Phone: 516-584-6400