1073111852 NPI number — JAM PHYSICAL THERAPY PC

Table of content: (NPI 1073111852)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073111852 NPI number — JAM PHYSICAL THERAPY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAM PHYSICAL THERAPY PC
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:
1073111852
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 AMERICA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST BABYLON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11704-4039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-325-1189
Provider Business Mailing Address Fax Number:
347-296-3235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
179 GREAT EAST NECK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST BABYLON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11704-8009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-325-1189
Provider Business Practice Location Address Fax Number:
347-296-3235
Provider Enumeration Date:
10/13/2020

Additional Information

Authorized Official

Authorized Official Last Name:
DICKEY
Authorized Official First Name:
WINDA
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL BILLER
Authorized Official Telephone Number:
347-638-3410

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A100000722 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1376856401 . This is a "NPI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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