Provider Demographics
NPI:1639562556
Name:NY PRIDE PHYISCAL THERAPY, P.C.
Entity Type:Organization
Organization Name:NY PRIDE PHYISCAL THERAPY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOHYUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-445-2346
Mailing Address - Street 1:13682 39TH AVE
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5515
Mailing Address - Country:US
Mailing Address - Phone:718-445-2346
Mailing Address - Fax:718-445-2348
Practice Address - Street 1:13682 39TH AVE
Practice Address - Street 2:6TH FLOOR
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5515
Practice Address - Country:US
Practice Address - Phone:718-445-2346
Practice Address - Fax:718-445-2348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019722-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02590958Medicaid
NY02590958Medicaid