Provider Demographics
NPI:1255479119
Name:NORTH SHORE PHYSICAL MEDICINE AND REHABILITATION SERVICES, PC
Entity Type:Organization
Organization Name:NORTH SHORE PHYSICAL MEDICINE AND REHABILITATION SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-621-4062
Mailing Address - Street 1:PO BOX 1357
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11709-0357
Mailing Address - Country:US
Mailing Address - Phone:516-794-4161
Mailing Address - Fax:516-794-9568
Practice Address - Street 1:4 EXPRESSWAY PLZ
Practice Address - Street 2:STE 110
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-2059
Practice Address - Country:US
Practice Address - Phone:516-621-4062
Practice Address - Fax:516-621-1848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167868-1225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW38421Medicare ID - Type UnspecifiedGROUP #