Basic Information
| Provider Information | |||||||||
| NPI: | 1255479119 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH SHORE PHYSICAL MEDICINE AND REHABILITATION SERVICES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1357 | ||||||||
| Address2: | |||||||||
| City: | BAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117090357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167944161 | ||||||||
| FaxNumber: | 5167949568 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 EXPRESSWAY PLZ | ||||||||
| Address2: | STE 110 | ||||||||
| City: | ROSLYN HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115772059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166214062 | ||||||||
| FaxNumber: | 5166211848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 11/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | ROOT | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5166214062 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | 167868-1 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.