Provider Demographics
NPI:1750758447
Name:PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, P.C.
Entity type:Organization
Organization Name:PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF ADMIN OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PABELLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-321-2447
Mailing Address - Street 1:2142 UTOPIA PKWY
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-4142
Mailing Address - Country:US
Mailing Address - Phone:516-321-2447
Mailing Address - Fax:914-517-2848
Practice Address - Street 1:1010 ROUTE 112
Practice Address - Street 2:SUITE 200
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3387
Practice Address - Country:US
Practice Address - Phone:631-476-4880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-28
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4WFH1Medicare PIN