Provider Demographics
NPI:1619512316
Name:BEACON PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:BEACON PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MEDRANO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:212-810-1881
Mailing Address - Street 1:16 BEACON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-1351
Mailing Address - Country:US
Mailing Address - Phone:212-810-1881
Mailing Address - Fax:
Practice Address - Street 1:16 BEACON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-1351
Practice Address - Country:US
Practice Address - Phone:212-810-1881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-17
Last Update Date:2019-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty