Provider Demographics
NPI:1619011152
Name:EISEN, ANDREW S
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:S
Last Name:EISEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 BEACH 121ST ST
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-1961
Mailing Address - Country:US
Mailing Address - Phone:917-855-1305
Mailing Address - Fax:
Practice Address - Street 1:168 BEACH 121ST ST
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-1961
Practice Address - Country:US
Practice Address - Phone:917-855-1305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-17
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33468225100000X
WAPT60046366225100000X
NY0369582251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33468OtherLICENSE
WAG8877239Medicare PIN