=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134458540
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARY GOLDUBER CARDIOLOGY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2009
-----------------------------------------------------
Last Update Date | 12/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 84 CRYSTAL CT
-----------------------------------------------------
City | HEWLETT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11557-2406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-261-9100
-----------------------------------------------------
Fax | 718-897-2915
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 84 CRYSTAL CT
-----------------------------------------------------
City | HEWLETT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11557-2406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-261-9100
-----------------------------------------------------
Fax | 718-897-2915
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GARY GOLDUBER
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 718-261-9100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 237371
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------