MEDICARE: 436 GWB MEDICAL OFFICE PC

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	207R00000X	Internal Medicine Physician
2	208D00000X	General Practice Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366952913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	436 GWB MEDICAL OFFICE PC

Provider Business Mailing Address
First Line	:	435 FORT WASHINGTON AVE APT 2B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10033-3527
Country	:	US
Telephone Number	:	212-923-0408
Fax Number	:	212-923-7051

Provider Business Practice Location Address
First Line	:	436 FORT WASHINGTON AVE APT 1A
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10033-3533
Country	:	US
Telephone Number	:	212-923-0408
Fax Number	:	212-923-7051

Authorized Official
Title or Position	:	MD
Name	:	JOSE A GORIS
Credential	:	MD
Telephone Number	:	212-923-0408

Provider Enumeration Date	:	10/10/2017
Last Update Date	:	10/10/2017

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