Provider Demographics
NPI:1851819023
Name:FAM PHYSICAL THERAPY OF MILLER PLACE PC
Entity Type:Organization
Organization Name:FAM PHYSICAL THERAPY OF MILLER PLACE PC
Other - Org Name:ADVANCED S.P.O.R.T.S. PHYSICAL THERAPY OF MILLER PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:STEPHANIE
Authorized Official - Last Name:DUMORNAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-820-9300
Mailing Address - Street 1:100 N BELLE MEAD RD
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3530
Mailing Address - Country:US
Mailing Address - Phone:631-689-5940
Mailing Address - Fax:631-689-5943
Practice Address - Street 1:275 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-2427
Practice Address - Country:US
Practice Address - Phone:631-364-8114
Practice Address - Fax:631-364-8117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014530-12081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY610109100OtherACS FEDERAL WORKERS COMPENSATION
NYP3151561OtherOXFORD
NY51376OtherVYTRA
NY218211POtherHIP
NY6697912OtherGHI
NY813473OtherEMPIRE PLAN (UHC)
NYQ04B71OtherBCBS