Provider Demographics
NPI:1609135888
Name:NEW YORK PHYSICAL MEDICINE CENTER
Entity Type:Organization
Organization Name:NEW YORK PHYSICAL MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KEOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-848-7974
Mailing Address - Street 1:1295 PORTLAND AVE
Mailing Address - Street 2:STE 9
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-2731
Mailing Address - Country:US
Mailing Address - Phone:585-544-6410
Mailing Address - Fax:585-544-9247
Practice Address - Street 1:1295 PORTLAND AVE
Practice Address - Street 2:STE 9
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-2731
Practice Address - Country:US
Practice Address - Phone:585-544-6410
Practice Address - Fax:585-544-9247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239194208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty