Provider Demographics
NPI:1932289550
Name:ADVANCED PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ADVANCED PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EFSTRATIOS
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONIADIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-821-4216
Mailing Address - Street 1:6642 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-3153
Mailing Address - Country:US
Mailing Address - Phone:718-821-4216
Mailing Address - Fax:718-821-4253
Practice Address - Street 1:6642 FOREST AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-3153
Practice Address - Country:US
Practice Address - Phone:718-821-4216
Practice Address - Fax:718-821-4253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013057208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01703Medicare ID - Type Unspecified