Provider Demographics
NPI:1669643359
Name:TRIBORO CARE PT PC
Entity Type:Organization
Organization Name:TRIBORO CARE PT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:FAWZI
Authorized Official - Last Name:TAWDROS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-886-1150
Mailing Address - Street 1:235 SHERIDAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3220
Mailing Address - Country:US
Mailing Address - Phone:718-886-1150
Mailing Address - Fax:718-886-7785
Practice Address - Street 1:13302 41ST AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5848
Practice Address - Country:US
Practice Address - Phone:718-886-1150
Practice Address - Fax:718-886-1185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2008-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027797174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02887823Medicaid
NYWYP1P1OtherMEDICARE GROUP