Provider Demographics
NPI:1710938444
Name:WYATT MEDICAL, LLC
Entity Type:Organization
Organization Name:WYATT MEDICAL, LLC
Other - Org Name:WYATT REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:PODOLSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, CLT-LANA
Authorized Official - Phone:732-222-8556
Mailing Address - Street 1:504 ALDRICH RD UNIT 1E
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07731-1978
Mailing Address - Country:US
Mailing Address - Phone:732-222-8556
Mailing Address - Fax:732-222-8663
Practice Address - Street 1:504 ALDRICH RD UNIT 1E
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:NJ
Practice Address - Zip Code:07731-1978
Practice Address - Country:US
Practice Address - Phone:732-222-8556
Practice Address - Fax:732-222-8663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherOUT OF NETWORK PROVIDER
NJ093230Medicare ID - Type UnspecifiedPROVIDER NUMBER
NJ6263420001Medicare NSC