Provider Demographics
NPI:1295965739
Name:TRISTATE PHYSICAL MEDICINE & REHABILITATION, P.C.
Entity type:Organization
Organization Name:TRISTATE PHYSICAL MEDICINE & REHABILITATION, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-367-0177
Mailing Address - Street 1:5822 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-2454
Mailing Address - Country:US
Mailing Address - Phone:718-549-3185
Mailing Address - Fax:718-884-5002
Practice Address - Street 1:5822 BROADWAY
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-2454
Practice Address - Country:US
Practice Address - Phone:718-549-3185
Practice Address - Fax:718-884-5002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183866208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty