Provider Demographics
NPI:1083681613
Name:ISLAND SPORTS PHYSICAL THERAPY OF CORAM PC
Entity Type:Organization
Organization Name:ISLAND SPORTS PHYSICAL THERAPY OF CORAM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RODEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT OCS
Authorized Official - Phone:631-732-3900
Mailing Address - Street 1:607 MIDDLE COUNTRY ROAD
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727
Mailing Address - Country:US
Mailing Address - Phone:631-732-3900
Mailing Address - Fax:631-732-3908
Practice Address - Street 1:607 MIDDLE COUNTRY ROAD
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727
Practice Address - Country:US
Practice Address - Phone:631-732-3900
Practice Address - Fax:631-732-3900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-02
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY14816OtherVYTRA
NY2C0907OtherHEALTHNET
NYA384995OtherOXFORD
NY14816OtherVYTRA