Provider Demographics
NPI:1689330342
Name:SPINE SPORTS & REHABILITATION MEDICINE, P.C.
Entity Type:Organization
Organization Name:SPINE SPORTS & REHABILITATION MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:MALKIE
Authorized Official - Last Name:BRUNNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-987-9837
Mailing Address - Street 1:359 YALE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2039
Mailing Address - Country:US
Mailing Address - Phone:516-987-9837
Mailing Address - Fax:516-531-8877
Practice Address - Street 1:123 MAPLE AVE STE LL
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-2240
Practice Address - Country:US
Practice Address - Phone:516-703-3580
Practice Address - Fax:516-531-8877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty