Provider Demographics
NPI:1225262785
Name:PHYSIOLOGIC CHIROPRACTIC & PHYSICAL THERAPY, PLLC.
Entity Type:Organization
Organization Name:PHYSIOLOGIC CHIROPRACTIC & PHYSICAL THERAPY, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GEHRMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:718-260-1000
Mailing Address - Street 1:409 FULTON ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201
Mailing Address - Country:US
Mailing Address - Phone:718-260-1000
Mailing Address - Fax:718-260-0072
Practice Address - Street 1:409 FULTON ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5103
Practice Address - Country:US
Practice Address - Phone:718-260-1000
Practice Address - Fax:718-260-0072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYXD010420-1111N00000X
NYX010420111N00000X
NY0081641225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6690370001OtherMCR DMERC PTAN
NYA100017686Medicare PIN