Provider Demographics
NPI:1952513384
Name:ADVANCED SPORTS PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:ADVANCED SPORTS PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:631-689-5940
Mailing Address - Street 1:100 N BELLE MEAD RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3455
Mailing Address - Country:US
Mailing Address - Phone:631-689-5940
Mailing Address - Fax:
Practice Address - Street 1:100 N BELLE MEAD RD
Practice Address - Street 2:SUITE A
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3455
Practice Address - Country:US
Practice Address - Phone:631-689-5940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-06
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014530-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4WBEIMedicare ID - Type Unspecified