Provider Demographics
NPI:1740564087
Name:GLEN COVE PHYSICAL MEDICINE, PC
Entity Type:Organization
Organization Name:GLEN COVE PHYSICAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PC OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-759-2032
Mailing Address - Street 1:7 VILLAGE SQ
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2515
Mailing Address - Country:US
Mailing Address - Phone:516-759-2032
Mailing Address - Fax:516-759-2117
Practice Address - Street 1:7 VILLAGE SQ
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2515
Practice Address - Country:US
Practice Address - Phone:516-759-2032
Practice Address - Fax:516-759-2117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111N00000X, 208100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1083705180OtherNPI
NY2373386OtherGHI
NY1347996OtherUNITEDHEALTH CARE
NY1083705180Other1199 UNION
NY8287078OtherAETNA HMO
NY100140595908OtherUNITEDHEALTH CARE COMMUNITY PLAN
NYP4407585OtherOXFORD
NY4191098OtherCIGNA
NY5239J1OtherEMPIRE BLUE CROSS BLUE SHIELD
NY830088POtherHIP
NY1347996OtherUNITEDHEALTH CARE
NYA400057985Medicare UPIN