Provider Demographics
NPI:1760506489
Name:CENTURION PHYSICAL THERAPY
Entity Type:Organization
Organization Name:CENTURION PHYSICAL THERAPY
Other - Org Name:FORMAN PHYSICAL THERAPY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:212-799-6700
Mailing Address - Street 1:152 W 57TH ST FL 6
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-3310
Mailing Address - Country:US
Mailing Address - Phone:212-799-6700
Mailing Address - Fax:212-799-4533
Practice Address - Street 1:152 W 57TH ST FL 6
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3310
Practice Address - Country:US
Practice Address - Phone:212-799-6700
Practice Address - Fax:212-799-4533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0174861225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1700082823OtherPHYSICAL THERAPISTS
NY1346244878OtherPHYSICAL THERAPIST