Provider Demographics
NPI:1023164142
Name:SOUTHERN NASSAU PHYSICAL THERAPY P C
Entity type:Organization
Organization Name:SOUTHERN NASSAU PHYSICAL THERAPY P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OCS, CSCS
Authorized Official - Phone:516-599-8734
Mailing Address - Street 1:44 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2519
Mailing Address - Country:US
Mailing Address - Phone:516-599-8734
Mailing Address - Fax:516-599-5969
Practice Address - Street 1:44 BROADWAY
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-2519
Practice Address - Country:US
Practice Address - Phone:516-599-8734
Practice Address - Fax:516-599-5969
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN NASSAU PT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-25
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ0WDJ1Medicare PIN