Provider Demographics
NPI:1376529107
Name:SEGAL, GLENN HARRIS (PT)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:HARRIS
Last Name:SEGAL
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 1:152 ISLIP AVE
Mailing Address - Street 2:STE.15
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-3225
Mailing Address - Country:US
Mailing Address - Phone:631-277-6767
Mailing Address - Fax:631-277-4311
Practice Address - Street 1:152 ISLIP AVE
Practice Address - Street 2:STE.15
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3225
Practice Address - Country:US
Practice Address - Phone:631-277-6767
Practice Address - Fax:631-277-4311
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017632-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01891565Medicaid
NYGS0Q4W1E1OtherMEDICARE PIN#
NYQ40891Medicare ID - Type UnspecifiedPROVIDER #