Provider Demographics
NPI:1043385206
Name:MAIN STREET PHYSICAL THERAPY AND HAND REHABILITATION OF KINGS PARK, PL
Entity Type:Organization
Organization Name:MAIN STREET PHYSICAL THERAPY AND HAND REHABILITATION OF KINGS PARK, PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FONTANA
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:631-269-6652
Mailing Address - Street 1:152 W MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754
Mailing Address - Country:US
Mailing Address - Phone:631-269-6652
Mailing Address - Fax:631-269-6654
Practice Address - Street 1:152 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754
Practice Address - Country:US
Practice Address - Phone:631-269-6652
Practice Address - Fax:631-269-6654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208100000X
NY011230208100000X
NY0227181208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q4WQ510Medicare ID - Type Unspecified