MEDICARE: GLEN COVE PHYSICAL MEDICINE, PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	111N00000X	Chiropractor	NY
2	225100000X	Physical Therapist	NY
3	208100000X	Physical Medicine & Rehabilitation Physician	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1083705180	OTHER	NY	NPI
2	2373386	OTHER	NY	GHI
3	1347996	OTHER	NY	UNITEDHEALTH CARE
4	1083705180	OTHER	NY	1199 UNION
5	8287078	OTHER	NY	AETNA HMO
6	100140595908	OTHER	NY	UNITEDHEALTH CARE COMMUNITY PLAN
7	P4407585	OTHER	NY	OXFORD
8	4191098	OTHER	NY	CIGNA
9	5239J1	OTHER	NY	EMPIRE BLUE CROSS BLUE SHIELD
10	830088P	OTHER	NY	HIP

General Provider Information

NPI Number	:	1740564087
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLEN COVE PHYSICAL MEDICINE, PC

Provider Business Mailing Address
First Line	:	7 VILLAGE SQ
Second Line	:
City	:	GLEN COVE
State	:	NY
Zip	:	11542-2515
Country	:	US
Telephone Number	:	516-759-2032
Fax Number	:	516-759-2117

Provider Business Practice Location Address
First Line	:	7 VILLAGE SQ
Second Line	:
City	:	GLEN COVE
State	:	NY
Zip	:	11542-2515
Country	:	US
Telephone Number	:	516-759-2032
Fax Number	:	516-759-2117

Authorized Official
Title or Position	:	PC OWNER
Name	:	ERIC S. ROTH
Credential	:	MD
Telephone Number	:	516-759-2032

Provider Enumeration Date	:	10/05/2011
Last Update Date	:	04/18/2012

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