Provider Demographics
NPI:1114255791
Name:PREMIER MEDICAL FOR SPORT & REHABILITATION, P.C.
Entity Type:Organization
Organization Name:PREMIER MEDICAL FOR SPORT & REHABILITATION, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMED
Authorized Official - Middle Name:E
Authorized Official - Last Name:ELEMAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-258-7203
Mailing Address - Street 1:PO BOX 290707
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-0707
Mailing Address - Country:US
Mailing Address - Phone:718-258-7203
Mailing Address - Fax:718-258-7202
Practice Address - Street 1:11027 72ND DR
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-5513
Practice Address - Country:US
Practice Address - Phone:718-258-7203
Practice Address - Fax:718-258-7202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199870208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG36003Medicare UPIN
NY943331Medicare PIN
NY94333EW501Medicare PIN