Provider Demographics
NPI:1073111852
Name:JAM PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:JAM PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:
Authorized Official - First Name:WINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-638-3410
Mailing Address - Street 1:1400 AMERICA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-4039
Mailing Address - Country:US
Mailing Address - Phone:917-325-1189
Mailing Address - Fax:347-296-3235
Practice Address - Street 1:179 GREAT EAST NECK RD
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-8009
Practice Address - Country:US
Practice Address - Phone:917-325-1189
Practice Address - Fax:347-296-3235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-13
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100000722Medicaid
NY1376856401OtherNPI