Basic Information
| Provider Information | |||||||||
| NPI: | 1417412958 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOLYAN MEDICAL ASSOCIATE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 E SHORE RD | ||||||||
| Address2: | |||||||||
| City: | KINGS POINT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110242128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167758605 | ||||||||
| FaxNumber: | 5167042058 | ||||||||
| Practice Location | |||||||||
| Address1: | 6902 AUSTIN ST | ||||||||
| Address2: | |||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113754233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187936800 | ||||||||
| FaxNumber: | 7182614312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2019 | ||||||||
| LastUpdateDate: | 02/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | GOLYAN | ||||||||
| AuthorizedOfficialFirstName: | FARAIDOON | ||||||||
| AuthorizedOfficialMiddleName: | DANIEL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5167758605 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 01895596 | 05 | NY | MEDICAID |