=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437507779
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GT MEDICAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2016
-----------------------------------------------------
Last Update Date | 06/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9436 58TH AVE # G4
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-947-7692
-----------------------------------------------------
Fax | 347-947-7680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9436 58TH AVE # G4
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11373-5149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-947-7692
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. QIAO DONG GUO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 347-947-7692
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 269058
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------