Provider Demographics
NPI:1366852584
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:VP OF ADMINISTRATIVE OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PABELLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-321-2447
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:212-692-9558
Mailing Address - Fax:212-692-9262
Practice Address - Street 1:521 5TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10175-0003
Practice Address - Country:US
Practice Address - Phone:212-692-9558
Practice Address - Fax:212-692-9262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-28
Last Update Date:2018-03-30
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