MEDICARE: ANDREAS GOMOLL ORTHOPAEDIC, PLLC

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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician

General Provider Information

NPI Number	:	1114691268
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANDREAS GOMOLL ORTHOPAEDIC, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 12204
Second Line	:
City	:	HAUPPAUGE
State	:	NY
Zip	:	11788-0614
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	523 E 72ND ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10021-4099
Country	:	US
Telephone Number	:	212-606-1775
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	ANDREAS HANS GOMOLL
Credential	:	MD
Telephone Number	:	617-610-4858

Provider Enumeration Date	:	08/03/2021
Last Update Date	:	10/13/2021

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