Provider Demographics
NPI:1083805535
Name:EMPIRE STATE PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:EMPIRE STATE PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:WONG-PAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:845-255-1925
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:NY
Mailing Address - Zip Code:12525-0188
Mailing Address - Country:US
Mailing Address - Phone:845-255-1925
Mailing Address - Fax:845-255-1925
Practice Address - Street 1:134 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW PALTZ
Practice Address - State:NY
Practice Address - Zip Code:12561-1128
Practice Address - Country:US
Practice Address - Phone:845-255-1925
Practice Address - Fax:845-255-1925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017188225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4W0H1Medicare PIN