Provider Demographics
NPI:1497027700
Name:EXECUTIVE PHYSICAL THERAPY PT
Entity Type:Organization
Organization Name:EXECUTIVE PHYSICAL THERAPY PT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPY ADMINISTRATOR
Authorized Official - Prefix:PROF
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:CECULIA
Authorized Official - Last Name:ANIBAL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-426-1515
Mailing Address - Street 1:7802 ROOSEVELT AVE STE 212
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6626
Mailing Address - Country:US
Mailing Address - Phone:718-426-1515
Mailing Address - Fax:718-426-0133
Practice Address - Street 1:7802 ROOSEVELT AVE STE 212
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6626
Practice Address - Country:US
Practice Address - Phone:718-426-1515
Practice Address - Fax:718-426-0133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========Medicare PIN