Provider Demographics
NPI:1811363161
Name:FITNESS AND RECOVERY MEDICAL PRACTICE, PC
Entity Type:Organization
Organization Name:FITNESS AND RECOVERY MEDICAL PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MACK LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-395-3691
Mailing Address - Street 1:369 WHITE PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:EASTCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10709-2805
Mailing Address - Country:US
Mailing Address - Phone:914-395-3691
Mailing Address - Fax:
Practice Address - Street 1:369 WHITE PLAINS RD
Practice Address - Street 2:
Practice Address - City:EASTCHESTER
Practice Address - State:NY
Practice Address - Zip Code:10709-2805
Practice Address - Country:US
Practice Address - Phone:914-395-3691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018927-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty