Provider Demographics
NPI:1245482454
Name:PREMIER PHYSICAL MEDICINE & REHABILITATION, PC
Entity type:Organization
Organization Name:PREMIER PHYSICAL MEDICINE & REHABILITATION, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-593-3030
Mailing Address - Street 1:56B MERRICK ROAD
Mailing Address - Street 2:
Mailing Address - City:VALLEYSTREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580
Mailing Address - Country:US
Mailing Address - Phone:516-593-3030
Mailing Address - Fax:
Practice Address - Street 1:56B MERRICK ROAD
Practice Address - Street 2:
Practice Address - City:VALLEYSTREAM
Practice Address - State:NY
Practice Address - Zip Code:11580
Practice Address - Country:US
Practice Address - Phone:516-593-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2075872081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02105008Medicaid
NY207587-7WOtherWORKER'S COMPENSATION
NY207587-7WOtherWORKER'S COMPENSATION
NY02105008Medicaid