Provider Demographics
NPI:1497744460
Name:TOBACK, FERN ROBIN (PT)
Entity Type:Individual
Prefix:MRS
First Name:FERN
Middle Name:ROBIN
Last Name:TOBACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 CLOVER LN
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-2723
Mailing Address - Country:US
Mailing Address - Phone:516-625-3407
Mailing Address - Fax:
Practice Address - Street 1:7050 AUSTIN ST
Practice Address - Street 2:ROOM 124
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4737
Practice Address - Country:US
Practice Address - Phone:718-520-8822
Practice Address - Fax:718-575-8403
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006489225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR75183Medicare UPIN