Provider Demographics
NPI:1548389737
Name:QUEENS- NASSAU GASTROENTEROLOGY P.C.
Entity Type:Organization
Organization Name:QUEENS- NASSAU GASTROENTEROLOGY P.C.
Other - Org Name:QUEENS- NASSAU GASTROENTEROLOGY P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-358-9007
Mailing Address - Street 1:2001 MARCUS AVE
Mailing Address - Street 2:SUITE W260
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1011
Mailing Address - Country:US
Mailing Address - Phone:516-358-9007
Mailing Address - Fax:516-358-9011
Practice Address - Street 1:2001 MARCUS AVE
Practice Address - Street 2:SUITE W260
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1011
Practice Address - Country:US
Practice Address - Phone:516-358-9007
Practice Address - Fax:516-358-9011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139570207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY80D021Medicare ID - Type Unspecified