Provider Demographics
NPI:1982990743
Name:ST JUDE'S PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ST JUDE'S PHYSICAL THERAPY
Other - Org Name:ST JUDE'S PEDIATRIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:347-524-0630
Mailing Address - Street 1:212 MACON ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2405
Mailing Address - Country:US
Mailing Address - Phone:347-524-0630
Mailing Address - Fax:646-224-8040
Practice Address - Street 1:7712 4TH AVE
Practice Address - Street 2:# 1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3402
Practice Address - Country:US
Practice Address - Phone:646-224-8040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-21
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028641225100000X
NY016896-1225XP0200X
NY020555-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400016264OtherMEDICARE
NY03130458Medicaid