Provider Demographics
NPI:1528191830
Name:PHYSICAL MEDICINE AND REHABILITATION OF NY
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE AND REHABILITATION OF NY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GAUTAM
Authorized Official - Middle Name:KAUSHIK
Authorized Official - Last Name:KHAKHAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-549-7260
Mailing Address - Street 1:9520 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1136
Mailing Address - Country:US
Mailing Address - Phone:718-459-1280
Mailing Address - Fax:
Practice Address - Street 1:3815 PUTNAM AVE W
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-2442
Practice Address - Country:US
Practice Address - Phone:718-549-7260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2182012081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty