Provider Demographics
NPI:1346296936
Name:KIMBALL, CHRISTOPHER (PT)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:
Last Name:KIMBALL
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 1:567 JERICHO TPKE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4505
Mailing Address - Country:US
Mailing Address - Phone:516-364-6720
Mailing Address - Fax:516-364-6722
Practice Address - Street 1:567 JERICHO TPKE
Practice Address - Street 2:SUITE 202
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4505
Practice Address - Country:US
Practice Address - Phone:516-364-6720
Practice Address - Fax:516-364-6722
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21476225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03248KMedicare ID - Type UnspecifiedGHI MEDICARE
NY03248KMedicare PIN