Provider Demographics
NPI:1457498180
Name:SPORTS MEDICINE & SPINE REHAB, PC
Entity Type:Organization
Organization Name:SPORTS MEDICINE & SPINE REHAB, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:GREGORACE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:516-485-5060
Mailing Address - Street 1:114 WHITNEY ST
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1831
Mailing Address - Country:US
Mailing Address - Phone:516-333-1452
Mailing Address - Fax:516-876-1038
Practice Address - Street 1:160 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-1317
Practice Address - Country:US
Practice Address - Phone:516-485-5060
Practice Address - Fax:516-485-4946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1985942081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG14802Medicare UPIN
NY310752Medicare ID - Type Unspecified