1932645181 NPI number — PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932645181 NPI number — PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, 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:
1932645181
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2142 UTOPIA PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITESTONE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11357-4142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-819-6805
Provider Business Mailing Address Fax Number:
347-841-9109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
279 SUNRISE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKVILLE CENTRE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11570-4925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-255-4263
Provider Business Practice Location Address Fax Number:
516-255-4050
Provider Enumeration Date:
01/12/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BRUSH
Authorized Official First Name:
KATHLEEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
718-819-6805

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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