Provider Demographics
NPI:1518435510
Name:SEDHOM, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:SEDHOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 E MAIN ST
Mailing Address - Street 2:APT 381
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ST. MAURICE PHYSICAL THERAPY
Practice Address - Street 2:899 BOWLING GREEN DR
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-6103
Practice Address - Country:US
Practice Address - Phone:631-209-5700
Practice Address - Fax:631-209-5180
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041598225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist