1457498180 NPI number — SPORTS MEDICINE & SPINE REHAB, PC

Table of content: (NPI 1457498180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457498180 NPI number — SPORTS MEDICINE & SPINE REHAB, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS MEDICINE & SPINE REHAB, 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:
1457498180
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
114 WHITNEY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTBURY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11590-1831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-333-1452
Provider Business Mailing Address Fax Number:
516-876-1038

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 N FRANKLIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HEMPSTEAD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11550-1317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-485-5060
Provider Business Practice Location Address Fax Number:
516-485-4946
Provider Enumeration Date:
01/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GREGORACE
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
GEORGE
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
516-485-5060

Provider Taxonomy Codes

  • Taxonomy code: 2081S0010X , with the licence number:  198594 , 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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