Provider Demographics
NPI:1275520918
Name:MADISON PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MADISON PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EHUD
Authorized Official - Last Name:AMIR
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-648-0888
Mailing Address - Street 1:3311 SHORE PKWY
Mailing Address - Street 2:APT. FF
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3956
Mailing Address - Country:US
Mailing Address - Phone:718-648-0888
Mailing Address - Fax:718-648-0411
Practice Address - Street 1:1514 VOORHIES AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235
Practice Address - Country:US
Practice Address - Phone:718-648-0888
Practice Address - Fax:718-648-0411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013940-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ7W4M1Medicare PIN