Provider Demographics
NPI:1912996141
Name:PREMIER PHYSICAL THERAPY AND WELLNESS, PC
Entity Type:Organization
Organization Name:PREMIER PHYSICAL THERAPY AND WELLNESS, PC
Other - Org Name:PREMIER PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:TATTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-249-5332
Mailing Address - Street 1:1536 3RD AVE
Mailing Address - Street 2:5TH FL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-2167
Mailing Address - Country:US
Mailing Address - Phone:212-861-2630
Mailing Address - Fax:
Practice Address - Street 1:170 E 77TH ST
Practice Address - Street 2:PROF. UNIT 2
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1912
Practice Address - Country:US
Practice Address - Phone:212-249-5332
Practice Address - Fax:212-249-9539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ1WCT1Medicare PIN