Provider Demographics
NPI:1841608841
Name:DEER PARK PHYSICAL THERAPY AND CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:DEER PARK PHYSICAL THERAPY AND CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BREDOW
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:631-242-4500
Mailing Address - Street 1:2103 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-1319
Mailing Address - Country:US
Mailing Address - Phone:631-242-4500
Mailing Address - Fax:631-242-0885
Practice Address - Street 1:2103 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-1319
Practice Address - Country:US
Practice Address - Phone:631-242-4500
Practice Address - Fax:631-242-0885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-23
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021022-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0401575OtherCIGNA
6697450OtherGHI
771360POtherHIP
NYQ13V53OtherBCBS
NYP3369855OtherOXFORD
NYQ5WXV1Medicare UPIN