=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508895491
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEITH J GOLKA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2006
-----------------------------------------------------
Last Update Date | 11/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 465 MONTAUK HIGHWAY SUITE B
-----------------------------------------------------
City | SAYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-567-6421
-----------------------------------------------------
Fax | 631-567-3574
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 465 MONTAUK HIGHWAY SUITE B
-----------------------------------------------------
City | SAYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-567-6421
-----------------------------------------------------
Fax | 631-567-3574
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 012434
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------