Basic Information
| Provider Information | |||||||||
| NPI: | 1669643359 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRIBORO CARE PT PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 SHERIDAN BLVD | ||||||||
| Address2: | |||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115013220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188861150 | ||||||||
| FaxNumber: | 7188867785 | ||||||||
| Practice Location | |||||||||
| Address1: | 13302 41ST AVE | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113555848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188861150 | ||||||||
| FaxNumber: | 7188861185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2008 | ||||||||
| LastUpdateDate: | 03/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | TAWDROS | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | FAWZI | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7188861150 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 027797 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 02887823 | 05 | NY | MEDICAID | WYP1P1 | 01 | NY | MEDICARE GROUP | OTHER |