Basic Information
| Provider Information | |||||||||
| NPI: | 1245340207 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOOD WILL MEDICAL, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 158 W 27TH ST | ||||||||
| Address2: | 11TH FLOOR SOUTH | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100016216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125632497 | ||||||||
| FaxNumber: | 2125630605 | ||||||||
| Practice Location | |||||||||
| Address1: | 5115 BEACH CHANNEL DR | ||||||||
| Address2: | |||||||||
| City: | FAR ROCKAWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116911042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125632497 | ||||||||
| FaxNumber: | 2125630605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 06/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | GALVIN | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2125632497 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02167279 | 05 | NY | MEDICAID |