Provider Demographics
NPI:1003959941
Name:EVERSHARP PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:EVERSHARP PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DISTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-803-2058
Mailing Address - Street 1:7215 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-1525
Mailing Address - Country:US
Mailing Address - Phone:718-803-2058
Mailing Address - Fax:718-426-9155
Practice Address - Street 1:7215 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-1525
Practice Address - Country:US
Practice Address - Phone:718-803-2058
Practice Address - Fax:718-426-9155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012611261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07971Medicare PIN