Provider Demographics
NPI:1629584818
Name:ST MICHAEL PT PC
Entity Type:Organization
Organization Name:ST MICHAEL PT PC
Other - Org Name:PHYSICAL THERAPY SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARGAYO
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:347-586-2271
Mailing Address - Street 1:8604 GRAND AVE APT 2K
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3409 MURRAY ST FL 2
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-3948
Practice Address - Country:US
Practice Address - Phone:718-888-1704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-26
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1077179924OtherMEDICARE, HMO, MAJOR MEDS