=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467966853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADDICTION WELLNESS SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2017
-----------------------------------------------------
Last Update Date | 01/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5504 N 2ND ST
-----------------------------------------------------
City | LOVES PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61111-5013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-997-4516
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3824 NORTHERN PIKE STE 600
-----------------------------------------------------
City | MONROEVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15146-2156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-457-0175
-----------------------------------------------------
Fax | 412-457-0179
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GAGANDEEP GOYAL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 267-226-4760
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP3000X
-----------------------------------------------------
Taxonomy Name | Pediatric Anesthesiology Physician
-----------------------------------------------------
License Number | MD438154
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------