Provider Demographics
NPI:1811955503
Name:MYSTIC PHYSICAL THERAPY ASSOCIATES PC
Entity type:Organization
Organization Name:MYSTIC PHYSICAL THERAPY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR MANAGING
Authorized Official - Prefix:MR
Authorized Official - First Name:LAZARUS
Authorized Official - Middle Name:SUREN
Authorized Official - Last Name:DONABEDIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-966-7226
Mailing Address - Street 1:100 FORT HILL RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340
Mailing Address - Country:US
Mailing Address - Phone:860-445-9433
Mailing Address - Fax:860-445-8802
Practice Address - Street 1:100 FORT HILL RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340
Practice Address - Country:US
Practice Address - Phone:860-445-9433
Practice Address - Fax:860-445-8802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
C01198Medicare ID - Type Unspecified