Basic Information
| Provider Information | |||||||||
| NPI: | 1700895646 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPORTSCARE PHYSICAL THERAPY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 814 FULTON ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FARMINGDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117353638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164201927 | ||||||||
| FaxNumber: | 5164201952 | ||||||||
| Practice Location | |||||||||
| Address1: | 814 FULTON ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FARMINGDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117353638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164201927 | ||||||||
| FaxNumber: | 5164201952 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FOX | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5164201927 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 010663-1 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 6601383 | 01 | NY | GHI | OTHER | 2C7574 | 01 | NY | HEALTHNET | OTHER | 41830 | 01 | NY | VYTRA | OTHER | 180617P | 01 | NY | HIP | OTHER |