Provider Demographics
NPI:1558429845
Name:MAURO, KENNETH (PT)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:MAURO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 NORTHERN BLVD STE 27
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4802
Mailing Address - Country:US
Mailing Address - Phone:516-829-0030
Mailing Address - Fax:516-466-7723
Practice Address - Street 1:475 NORTHERN BLVD STE 11
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4802
Practice Address - Country:US
Practice Address - Phone:516-829-0030
Practice Address - Fax:516-466-7723
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020538225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQM2341Medicare ID - Type UnspecifiedEMPIRE MEDICARE
NY05048Medicare ID - Type UnspecifiedGHI MEDICARE