Provider Demographics
NPI:1003917899
Name:OLD BROOKVILLE PHYSICAL THERAPY & SPORTS REHABILITATION, P.C.
Entity Type:Organization
Organization Name:OLD BROOKVILLE PHYSICAL THERAPY & SPORTS REHABILITATION, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDRIC
Authorized Official - Middle Name:JOEL
Authorized Official - Last Name:SCHWARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:516-554-7165
Mailing Address - Street 1:13 HEMLOCK LN
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-1432
Mailing Address - Country:US
Mailing Address - Phone:516-554-7165
Mailing Address - Fax:516-625-7701
Practice Address - Street 1:55 BRYANT AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1139
Practice Address - Country:US
Practice Address - Phone:516-554-7165
Practice Address - Fax:516-625-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3509225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ53451Medicare ID - Type Unspecified