Provider Demographics
NPI:1477710994
Name:PHYSICAL MEDICINE & REHABILITATION OF BROOKHAVEN, PC
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE & REHABILITATION OF BROOKHAVEN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAPIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-654-2473
Mailing Address - Street 1:268 MEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1221
Mailing Address - Country:US
Mailing Address - Phone:631-654-2473
Mailing Address - Fax:
Practice Address - Street 1:268 MEDFORD AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1221
Practice Address - Country:US
Practice Address - Phone:631-654-2473
Practice Address - Fax:631-654-0217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125974-1261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWCK241Medicare PIN