Provider Demographics
NPI:1356548457
Name:PT REHABILITATION PC
Entity type:Organization
Organization Name:PT REHABILITATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MORDUKHAY
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:917-846-9645
Mailing Address - Street 1:6393 FITCHETT ST
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4830
Mailing Address - Country:US
Mailing Address - Phone:917-846-9645
Mailing Address - Fax:718-897-5162
Practice Address - Street 1:6393 FITCHETT ST
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4830
Practice Address - Country:US
Practice Address - Phone:917-846-9645
Practice Address - Fax:718-897-5162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022991225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02623265Medicaid