Basic Information
| Provider Information | |||||||||
| NPI: | 1114118858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRYAGIN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS,PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KRYAGIN | ||||||||
| OtherFirstName: | MICHAEL | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSPT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 305 W GRAND AVE STE 500 | ||||||||
| Address2: | |||||||||
| City: | MONTVALE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076451813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2013918282 | ||||||||
| FaxNumber: | 2013918299 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 W GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | MONTVALE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076451813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2012918282 | ||||||||
| FaxNumber: | 2013918299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA00892000 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.