Provider Demographics
NPI:1578141818
Name:PERFORMANCE PHYSICAL MEDICINE
Entity Type:Organization
Organization Name:PERFORMANCE PHYSICAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WRAITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:914-661-8444
Mailing Address - Street 1:323 BERGEN BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:NJ
Mailing Address - Zip Code:07022-1334
Mailing Address - Country:US
Mailing Address - Phone:201-945-9993
Mailing Address - Fax:201-945-8873
Practice Address - Street 1:150 UNION AVE FL 2
Practice Address - Street 2:
Practice Address - City:EAST RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07073-1917
Practice Address - Country:US
Practice Address - Phone:201-414-9545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty