Provider Demographics
NPI:1053403162
Name:GOLD COAST INTERNAL MEDICINE
Entity type:Organization
Organization Name:GOLD COAST INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALDO
Authorized Official - Middle Name:EMERSON
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:773-525-1900
Mailing Address - Street 1:3000 N HALSTED STREET
Mailing Address - Street 2:SUITE 303
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5190
Mailing Address - Country:US
Mailing Address - Phone:773-525-1900
Mailing Address - Fax:773-525-1911
Practice Address - Street 1:3000 N HALSTED STREET
Practice Address - Street 2:SUITE 303
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5190
Practice Address - Country:US
Practice Address - Phone:773-525-1900
Practice Address - Fax:773-525-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1623742OtherBLUE CROSS BLUE SHIELD
IL72761OtherHUMANA
IL72761OtherHUMANA
ILL78710Medicare ID - Type Unspecified
IL584760Medicare PIN