Provider Demographics
NPI:1548492226
Name:GATEWAY PHYSICIAN GROUP PLLC
Entity type:Organization
Organization Name:GATEWAY PHYSICIAN GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:GODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-858-3263
Mailing Address - Street 1:186 JORALEMON ST
Mailing Address - Street 2:8TH FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-4326
Mailing Address - Country:US
Mailing Address - Phone:718-858-3263
Mailing Address - Fax:
Practice Address - Street 1:186 JORALEMON ST
Practice Address - Street 2:8TH FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4326
Practice Address - Country:US
Practice Address - Phone:718-858-3263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-14
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185657207RR0500X
NY222545208100000X
NY239276208VP0014X
NY096783208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty