Provider Demographics
NPI:1780733212
Name:PHYSICAL THERAPY SPORTS REHAB
Entity type:Organization
Organization Name:PHYSICAL THERAPY SPORTS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHYSICAL THERAPY
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:BRONSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:732-636-5151
Mailing Address - Street 1:585 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-1104
Mailing Address - Country:US
Mailing Address - Phone:732-636-5151
Mailing Address - Fax:732-602-0046
Practice Address - Street 1:585 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095-1104
Practice Address - Country:US
Practice Address - Phone:732-636-5151
Practice Address - Fax:732-602-0046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJA495698OtherOXFORD
NJQ0W961OtherORTHONET EMPIRE BC
NJ0120701OtherCIGNA OPEN ACCESS PLUS
NJ3K4352OtherHEALTHNET
NJ316649Medicare Oscar/Certification