Provider Demographics
NPI:1376593368
Name:BACK ON TRACK, P.C.
Entity Type:Organization
Organization Name:BACK ON TRACK, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SISUN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:617-730-5337
Mailing Address - Street 1:721 RESERVOIR AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-4430
Mailing Address - Country:US
Mailing Address - Phone:401-946-4250
Mailing Address - Fax:
Practice Address - Street 1:1180 BEACON ST
Practice Address - Street 2:SUITE 6-C
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3838
Practice Address - Country:US
Practice Address - Phone:617-730-5337
Practice Address - Fax:617-730-5461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY65633OtherBCBSMA GROUP #
MAPT0067Medicare ID - Type UnspecifiedGROUP ID#
MAPT0182Medicare ID - Type UnspecifiedGROUP ID # OT SERVICES