Provider Demographics
NPI:1710445846
Name:ACTIVE LIFE HEALTH OF NY PC
Entity Type:Organization
Organization Name:ACTIVE LIFE HEALTH OF NY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN & CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-928-1697
Mailing Address - Street 1:PO BOX 772199
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-2223
Mailing Address - Country:US
Mailing Address - Phone:646-586-9333
Mailing Address - Fax:646-571-0807
Practice Address - Street 1:300 E MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2900
Practice Address - Country:US
Practice Address - Phone:631-656-8796
Practice Address - Fax:631-333-7322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-07
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty