1750471124 NPI number — THERA DYNAMIC PHYSICAL THERAPY P.C

Table of content: (NPI 1750471124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750471124 NPI number — THERA DYNAMIC PHYSICAL THERAPY P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERA DYNAMIC PHYSICAL THERAPY 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:
1750471124
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1443 28TH AVE APT 2D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG ISLAND CITY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11102-3663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-939-4166
Provider Business Mailing Address Fax Number:
347-732-9011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4702 47TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSIDE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11377-6125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-532-4705
Provider Business Practice Location Address Fax Number:
347-494-5641
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDRES
Authorized Official First Name:
LEE-ZEL MAY
Authorized Official Middle Name:
CARINGAL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
347-494-5684

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  025591-0 , 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: 2766209 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1263296P . This is a "EMBLEM HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: OP025591 . This is a "METROPLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: PT025591-A85 . This is a "HEALTHFIRST" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01941401 . This is a "EMPIRE BCBS HEALTHPLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P4059437 . This is a "OXFORD FREEDOM" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: PH0434 . This is a "ELDER PLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02837832 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1760591465-01 . This is a "VILLAGE CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 82ADC1 . This is a "EMPIRE BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 841087 . This is a "OPTUM HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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