Basic Information
Provider Information | |||||||||
NPI: | 1366959926 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REAL PHYSICAL THERAPY PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1752 FRANCIS LEWIS BLVD | ||||||||
Address2: |   | ||||||||
City: | WHITESTONE | ||||||||
State: | NY | ||||||||
PostalCode: | 113573247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1752 FRANCIS LEWIS BLVD | ||||||||
Address2: |   | ||||||||
City: | WHITESTONE | ||||||||
State: | NY | ||||||||
PostalCode: | 113573247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7187469494 | ||||||||
FaxNumber: | 7187464963 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/04/2018 | ||||||||
LastUpdateDate: | 01/04/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ABDEL SALAM | ||||||||
AuthorizedOfficialFirstName: | HESHAM | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | PT | ||||||||
AuthorizedOfficialTelephone: | 6072228794 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.