Provider Demographics
NPI:1467826602
Name:200 BROADWAY PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:200 BROADWAY PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FARHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSTAMI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:914-631-1919
Mailing Address - Street 1:200 S BROADWAY STE 2-2
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-4500
Mailing Address - Country:US
Mailing Address - Phone:914-631-1919
Mailing Address - Fax:914-631-1943
Practice Address - Street 1:200 S BROADWAY STE 2-2
Practice Address - Street 2:
Practice Address - City:TARRYTOWN
Practice Address - State:NY
Practice Address - Zip Code:10591-4500
Practice Address - Country:US
Practice Address - Phone:914-631-1919
Practice Address - Fax:914-631-1943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-27
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027552174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400066859Medicare PIN