Provider Demographics
NPI:1093984395
Name:MONTCLAIR PHYSICAL THERAPY ASSOCIATES PA
Entity Type:Organization
Organization Name:MONTCLAIR PHYSICAL THERAPY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:A
Authorized Official - Last Name:EDELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:973-744-9098
Mailing Address - Street 1:47 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2717
Mailing Address - Country:US
Mailing Address - Phone:973-744-9098
Mailing Address - Fax:973-744-3799
Practice Address - Street 1:47 S PARK ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2717
Practice Address - Country:US
Practice Address - Phone:973-744-9098
Practice Address - Fax:973-744-3799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA02640261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ675748RGGMedicare PIN