MEDICARE: GOLD COAST INTERNAL MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1623742	OTHER	IL	BLUE CROSS BLUE SHIELD
2	72761	OTHER	IL	HUMANA

General Provider Information

NPI Number	:	1053403162
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLD COAST INTERNAL MEDICINE

Provider Business Mailing Address
First Line	:	3000 N HALSTED STREET
Second Line	:	SUITE 303
City	:	CHICAGO
State	:	IL
Zip	:	60657-5190
Country	:	US
Telephone Number	:	773-525-1900
Fax Number	:	773-525-1911

Provider Business Practice Location Address
First Line	:	3000 N HALSTED STREET
Second Line	:	SUITE 303
City	:	CHICAGO
State	:	IL
Zip	:	60657-5190
Country	:	US
Telephone Number	:	773-525-1900
Fax Number	:	773-525-1911

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WALDO EMERSON HARVEY JR.
Credential	:	M.D.
Telephone Number	:	773-525-1900

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	08/22/2020

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Directions to “GOLD COAST INTERNAL MEDICINE ” Practice Location

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