Provider Demographics
NPI:1104975036
Name:SAMUEL K GOOLDY, MD PC
Entity type:Organization
Organization Name:SAMUEL K GOOLDY, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:GOOLDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-724-6611
Mailing Address - Street 1:1 OXFORD RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-2651
Mailing Address - Country:US
Mailing Address - Phone:315-724-6611
Mailing Address - Fax:315-724-6366
Practice Address - Street 1:1 OXFORD RD
Practice Address - Street 2:SUITE 304
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-2651
Practice Address - Country:US
Practice Address - Phone:315-724-6611
Practice Address - Fax:315-724-6366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00582774Medicaid
40075DMedicare ID - Type UnspecifiedINDIVIDUAL NUMBER
NYB82226Medicare UPIN
NY00582774Medicaid