Basic Information
| Provider Information | |||||||||
| NPI: | 1366569352 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BAY MEDICAL CARE P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | CENTER MORICHES | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318787134 | ||||||||
| FaxNumber: | 6318785118 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | CENTER MORICHES | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318787134 | ||||||||
| FaxNumber: | 6318785118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GOLDMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6318787134 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 207P00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.