Provider Demographics
NPI:1710302369
Name:PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP OF ADMINISTRATIVE OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:AGRELO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-321-2400
Mailing Address - Street 1:576 BROADHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-5002
Mailing Address - Country:US
Mailing Address - Phone:516-321-2400
Mailing Address - Fax:
Practice Address - Street 1:92 BROADWAY
Practice Address - Street 2:SUITE 102
Practice Address - City:GREENLAWN
Practice Address - State:NY
Practice Address - Zip Code:11740-1328
Practice Address - Country:US
Practice Address - Phone:631-262-7855
Practice Address - Fax:631-262-7854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-19
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4WFH1Medicare PIN