Provider Demographics
NPI:1326585498
Name:PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-359-5859
Mailing Address - Street 1:576 BROADHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-5002
Mailing Address - Country:US
Mailing Address - Phone:631-359-5859
Mailing Address - Fax:631-396-0865
Practice Address - Street 1:333 W 52ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-6238
Practice Address - Country:US
Practice Address - Phone:646-912-9086
Practice Address - Fax:646-657-0499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-26
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4WFH1Medicare PIN