Provider Demographics
NPI:1568816254
Name:GOLD COAST OSTEOPATHIC, PSC
Entity Type:Organization
Organization Name:GOLD COAST OSTEOPATHIC, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-553-6055
Mailing Address - Street 1:680 N LAKE SHORE DR STE 1040
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-8718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:680 N LAKE SHORE DR
Practice Address - Street 2:SUITE 1040
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4546
Practice Address - Country:US
Practice Address - Phone:773-554-6055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA243290204D00000X, 207Q00000X
IN02004367B204D00000X
NY261752204D00000X, 207Q00000X
IL204D00000X, 207Q00000X
IN02004367A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty