Provider Demographics
NPI:1598041428
Name:PHYSICAL MEDICINE & DIAGNOSTIC TESTING PC
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE & DIAGNOSTIC TESTING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLIFTON
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:BURT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-342-0746
Mailing Address - Street 1:PO BOX 473
Mailing Address - Street 2:
Mailing Address - City:NEW HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:10958-0473
Mailing Address - Country:US
Mailing Address - Phone:845-342-0746
Mailing Address - Fax:845-342-1397
Practice Address - Street 1:54 DOLSON AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-6424
Practice Address - Country:US
Practice Address - Phone:845-342-1247
Practice Address - Fax:845-342-1397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251765174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1588843163OtherNPI
NY2517654WOtherWORKERS COMPENSATION NUMBER