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
StateLicense IDTaxonomies
NY015401225100000X, 261QP2000X
2251C2600X, 2251E1300X, 2251G0304X, 2251H1200X, 2251H1300X, 2251P0200X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251C2600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistCardiopulmonaryGroup - Multi-Specialty
No2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, ClinicalGroup - Multi-Specialty
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHandGroup - Multi-Specialty
No2251H1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHuman FactorsGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02184710Medicaid
NY4C7780OtherHEALTHNET
NYP2666818OtherOXFORD
NY19447POtherHIP
NYQQ1073OtherEMPIRE BC/BS
NY4C7780OtherHEALTHNET