Provider Demographics
NPI:1790984425
Name:MED PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:MED PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FARHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:HAERI
Authorized Official - Suffix:
Authorized Official - Credentials:PT DPT
Authorized Official - Phone:631-385-0066
Mailing Address - Street 1:1035 WESTMINSTER AVE
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746
Mailing Address - Country:US
Mailing Address - Phone:631-385-0066
Mailing Address - Fax:631-385-0770
Practice Address - Street 1:775 PARK AVE
Practice Address - Street 2:SUITE 200-12
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743
Practice Address - Country:US
Practice Address - Phone:631-385-0066
Practice Address - Fax:631-385-0770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0155911225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02019134Medicaid
216B61Medicare PIN