Provider Demographics
NPI:1952414567
Name:BACK TO SPORTS PHYSICAL THERAPY, P.C.
Entity Type:Organization
Organization Name:BACK TO SPORTS PHYSICAL THERAPY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:HUPPERT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:646-707-0400
Mailing Address - Street 1:1395 LEXINGTON AVE
Mailing Address - Street 2:MEZZANINE LEVEL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1395 LEXINGTON AVE
Practice Address - Street 2:MEZZANINE LEVEL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-1612
Practice Address - Country:US
Practice Address - Phone:646-707-0400
Practice Address - Fax:646-707-0380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020331-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4WDB1Medicare PIN