Provider Demographics
NPI:1114479474
Name:ELGENDY, MOHAMED MOUNER MOHAMED (PT)
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:MOUNER MOHAMED
Last Name:ELGENDY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6902 RIDGE BLVD APT C6
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-1234
Mailing Address - Country:US
Mailing Address - Phone:347-497-9152
Mailing Address - Fax:
Practice Address - Street 1:599 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-3762
Practice Address - Country:US
Practice Address - Phone:347-567-7551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-02
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009199225200000X
NY045939225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11114479474Medicaid