Provider Demographics
NPI:1740621697
Name:PRO FORM PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:PRO FORM PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HANNA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:917-545-9249
Mailing Address - Street 1:95-22 63RD ROAD
Mailing Address - Street 2:SUITE 412
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1142
Mailing Address - Country:US
Mailing Address - Phone:718-618-0052
Mailing Address - Fax:718-534-4135
Practice Address - Street 1:1973 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4404
Practice Address - Country:US
Practice Address - Phone:718-618-0052
Practice Address - Fax:718-534-4135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-08
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025663174400000X
NY021421174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty