Provider Demographics
NPI:1710492251
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:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-819-6805
Mailing Address - Street 1:2142 UTOPIA PKWY
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-4142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:74 COMMERCE AVE STE 3
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-3105
Practice Address - Country:US
Practice Address - Phone:631-369-9110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty