1649324450 NPI number — OPTIMA PHYSICAL THERAPY REHABILITATION PC

Table of content: (NPI 1649324450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649324450 NPI number — OPTIMA PHYSICAL THERAPY REHABILITATION PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMA PHYSICAL THERAPY REHABILITATION 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:
1649324450
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:
PO BOX 1031
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LODI
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07644-7031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-324-8166
Provider Business Mailing Address Fax Number:
718-324-7539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4626 WHITE PLAINS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10470-1610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-324-8166
Provider Business Practice Location Address Fax Number:
718-324-7539
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OLOKUNGBEMI
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
AKINLOYE
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
718-324-8166

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  015375 , 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: 660533 . This is a "GHI PPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: QP768 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000073981-B . This is a "GHI HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 105663900 . This is a "DEPT. OF LABOR" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: DE3680 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 05714G . This is a "GHI MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 121300P . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P-11231046 . This is a "MULTIPLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 228870 . This is a "WELLCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0P015375 . This is a "METROPLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2292361 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01701817 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201130400016 . This is a "AFFINITY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 6202200 . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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