=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013087469
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB KREHBIEL GOERTZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2006
-----------------------------------------------------
Last Update Date | 11/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | FIRST AVENUE AT 16TH STREET BETH ISRAEL MEDICAL CENTER DEPT. OF EMERGENCY MEDICINE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-420-2847
-----------------------------------------------------
Fax | 212-420-2863
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 235 W 102ND ST APT. 17N
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10025-8400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-842-7003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 221907
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------