Provider Demographics
NPI:1750733788
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:773-554-6055
Mailing Address - Street 1:680 N LAKE SHORE DR
Mailing Address - Street 2:SUITE 1040
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:773-554-6055
Mailing Address - Fax:
Practice Address - Street 1:680 N LAKE SHORE DR STE 1040
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-8718
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:2016-07-01
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1568816254OtherILLINOIS STATE
IL1568816254OtherILLINOIS STATE