Provider Demographics
NPI: | 1508844036 |
---|---|
Name: | FRESH POND PHYSICAL THERAPY, P.C |
Entity Type: | Organization |
Organization Name: | FRESH POND PHYSICAL THERAPY, P.C |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | BILLING & COLLECTION DEPT. HEAD |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JENNY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | TAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 718-456-2543 |
Mailing Address - Street 1: | 68-05 FRESH POND ROAD |
Mailing Address - Street 2: | |
Mailing Address - City: | RIDGEWOOD |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 11385 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 718-456-2545 |
Mailing Address - Fax: | 718-559-6784 |
Practice Address - Street 1: | 6805 FRESH POND RD |
Practice Address - Street 2: | |
Practice Address - City: | RIDGEWOOD |
Practice Address - State: | NY |
Practice Address - Zip Code: | 11385-5200 |
Practice Address - Country: | US |
Practice Address - Phone: | 718-456-2545 |
Practice Address - Fax: | 718-559-6784 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-01-04 |
Last Update Date: | 2016-05-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 015401 | 225100000X, 261QP2000X |
2251C2600X, 2251E1300X, 2251G0304X, 2251H1200X, 2251H1300X, 2251P0200X, 2251X0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 2251C2600X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Cardiopulmonary | Group - Multi-Specialty |
No | 2251E1300X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Electrophysiology, Clinical | Group - Multi-Specialty |
No | 2251G0304X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics | Group - Multi-Specialty |
No | 2251H1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand | Group - Multi-Specialty |
No | 2251H1300X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Human Factors | Group - Multi-Specialty |
No | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | Group - Multi-Specialty |
No | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 02184710 | Medicaid | |
NY | 4C7780 | Other | HEALTHNET |
NY | P2666818 | Other | OXFORD |
NY | 19447P | Other | HIP |
NY | QQ1073 | Other | EMPIRE BC/BS |
NY | 4C7780 | Other | HEALTHNET |