Provider Demographics
NPI:1659476968
Name:NY PHYSICAL THERAPY & WELLNESS, MELVILLE, PLLC
Entity Type:Organization
Organization Name:NY PHYSICAL THERAPY & WELLNESS, MELVILLE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BREDOW
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:631-694-0005
Mailing Address - Street 1:1800 WALT WHITMAN RD STE 120
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3237
Mailing Address - Country:US
Mailing Address - Phone:631-694-0005
Mailing Address - Fax:631-694-0007
Practice Address - Street 1:535 BROADHOLLOW RD
Practice Address - Street 2:SUITE A10
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3713
Practice Address - Country:US
Practice Address - Phone:631-694-0005
Practice Address - Fax:631-694-0007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021022-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY173738POtherHIP
NYQ13V52OtherBC/BS
NYQ13V52OtherBC/BS