1750782256 NPI number — DEER PARK PHYSICAL THERAPY & CHIROPRACTIC

Table of content: (NPI 1750782256)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750782256 NPI number — DEER PARK PHYSICAL THERAPY & CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEER PARK PHYSICAL THERAPY & CHIROPRACTIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750782256
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2103 DEER PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEER PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11729-1319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-242-4500
Provider Business Mailing Address Fax Number:
631-242-0885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2103 DEER PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEER PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11729-1319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-242-4500
Provider Business Practice Location Address Fax Number:
631-242-0885
Provider Enumeration Date:
09/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BREDOW
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICAL THERAPY, OWNER
Authorized Official Telephone Number:
516-315-2010

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  021022-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0401575 . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 825077 . This is a "ACN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0401575 . This is a "ORTHONET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P3369855 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 825077 . This is a "MPN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2166308 . This is a "UHC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: Q13V53 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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