Provider Demographics
NPI:1427385392
Name:FIDELITY PHYSICAL THERAPY AND REHABILITATION PT,PC
Entity Type:Organization
Organization Name:FIDELITY PHYSICAL THERAPY AND REHABILITATION PT,PC
Other - Org Name:FIDELITY PHYSICAL THERAPY AND REHABILITATION PT,PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BENEDITO
Authorized Official - Middle Name:PAULINO
Authorized Official - Last Name:DA SILVA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-803-8078
Mailing Address - Street 1:4047 75TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1011
Mailing Address - Country:US
Mailing Address - Phone:718-803-8078
Mailing Address - Fax:718-803-3568
Practice Address - Street 1:4047 75TH ST FL 1
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1011
Practice Address - Country:US
Practice Address - Phone:718-803-8078
Practice Address - Fax:718-803-3568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-12
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023904-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03134654Medicaid
NY1467583831Medicare NSC