Provider Demographics
NPI:1750782256
Name:DEER PARK PHYSICAL THERAPY & CHIROPRACTIC
Entity type:Organization
Organization Name:DEER PARK PHYSICAL THERAPY & CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPY, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:BREDOW
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:516-315-2010
Mailing Address - Street 1:2103 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-1319
Mailing Address - Country:US
Mailing Address - Phone:631-242-4500
Mailing Address - Fax:631-242-0885
Practice Address - Street 1:2103 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-1319
Practice Address - Country:US
Practice Address - Phone:631-242-4500
Practice Address - Fax:631-242-0885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021022-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0401575OtherCIGNA
NY825077OtherACN
NY0401575OtherORTHONET
P3369855OtherOXFORD
NY825077OtherMPN
NY2166308OtherUHC
Q13V53OtherBCBS
NY2166308OtherUHC