MEDICARE: COSMETIQUE DERMATOLOGY, LASER & PLASTIC SURGERY, LLP

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	208200000X	Plastic Surgery Physician	147060-1	NY
2	207ND0101X	MOHS-Micrographic Surgery Physician	146515	NY

General Provider Information

NPI Number	:	1710987227
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COSMETIQUE DERMATOLOGY, LASER & PLASTIC SURGERY, LLP

Provider Business Mailing Address
First Line	:	31 NORTHERN BLVD
Second Line	:
City	:	GREENVALE
State	:	NY
Zip	:	11548-1320
Country	:	US
Telephone Number	:	516-484-9000
Fax Number	:	516-484-7549

Provider Business Practice Location Address
First Line	:	31 NORTHERN BLVD
Second Line	:
City	:	GREENVALE
State	:	NY
Zip	:	11548-1320
Country	:	US
Telephone Number	:	516-484-9000
Fax Number	:	516-484-7549

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. ROBERT H GOTKIN
Credential	:	MD
Telephone Number	:	516-484-9000

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	06/26/2008

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