1366779787 NPI number — PREMIER MEDICAL FOR SPORT & REHABILITATION, P.C.

Table of content: DR. KELLEY RAE LOCKHART M.D. (NPI 1033192679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366779787 NPI number — PREMIER MEDICAL FOR SPORT & REHABILITATION, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER MEDICAL FOR SPORT & REHABILITATION, P.C.
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:
1366779787
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 290707
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11229-0707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-258-7203
Provider Business Mailing Address Fax Number:
718-258-7202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3857 KINGS HWY
Provider Second Line Business Practice Location Address:
STE 1-I
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-258-7203
Provider Business Practice Location Address Fax Number:
718-258-7202
Provider Enumeration Date:
11/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ELEMAM
Authorized Official First Name:
AHMED
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
718-258-7203

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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