Basic Information
| Provider Information | |||||||||
| NPI: | 1164469755 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOULD | ||||||||
| FirstName: | NATHANIEL | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | SLOCUM DICKSON MEDICAL GROUP PLLC | ||||||||
| Address2: | 1729 BURRSTONE ROAD | ||||||||
| City: | NEW HARTFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157981700 | ||||||||
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| Practice Location | |||||||||
| Address1: | SLOCUM DICKSON MEDICAL GROUP PLLC | ||||||||
| Address2: | 1729 BURRSTONE ROAD | ||||||||
| City: | NEW HARTFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157981700 | ||||||||
| FaxNumber: | 3157981707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 05/31/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 243697 | NY | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 02866104 | 05 | NY | MEDICAID |