Provider Demographics
NPI:1831125327
Name:NY SPINE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:NY SPINE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:HATAMI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:631-447-6100
Mailing Address - Street 1:475 E MAIN ST
Mailing Address - Street 2:SUITE 103-105
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3121
Mailing Address - Country:US
Mailing Address - Phone:631-447-6100
Mailing Address - Fax:631-447-6126
Practice Address - Street 1:475 E MAIN ST
Practice Address - Street 2:SUITE 103-105
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3121
Practice Address - Country:US
Practice Address - Phone:631-447-6100
Practice Address - Fax:631-447-6126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016816-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQBW012Medicare ID - Type UnspecifiedPHYSICAL THERAPY
NYQBW011Medicare ID - Type UnspecifiedPHYSICAL THERAPY
NY03838Medicare PIN