Provider Demographics
NPI:1457437824
Name:MAGNA PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:MAGNA PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:
Authorized Official - First Name:ALEKSANDR
Authorized Official - Middle Name:
Authorized Official - Last Name:LIPEL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-714-0700
Mailing Address - Street 1:3715 MERMAID AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-1218
Mailing Address - Country:US
Mailing Address - Phone:718-714-0700
Mailing Address - Fax:
Practice Address - Street 1:1601 GRAVESEND NECK RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4430
Practice Address - Country:US
Practice Address - Phone:718-714-0700
Practice Address - Fax:718-934-3336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-28
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023424225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02202940Medicaid
NYQ3W8C1Medicare ID - Type Unspecified
NY02202940Medicaid