1124414024 NPI number — OLD FARM PHYSICAL THERAPY, PLLC

Table of content: DR. MARK EDWARD SHEPHERD JR. M.D., M.P.H. (NPI 1154300747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124414024 NPI number — OLD FARM PHYSICAL THERAPY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OLD FARM PHYSICAL THERAPY, PLLC
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:
1124414024
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
81 OLD FARM RD S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLEASANTVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10570-1505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
81 OLD FARM RD S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLEASANTVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10570-1505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-224-9679
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
FIORE
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
914-224-9679

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  025866 , 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)





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