Basic Information
Provider Information | |||||||||
NPI: | 1831190453 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROEX PHYSICAL THERAPY, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 576 BROADHOLLOW RD | ||||||||
Address2: |   | ||||||||
City: | MELVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 117475002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6313595859 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 300 TRADE CENTER | ||||||||
Address2: | SUITE 1650 | ||||||||
City: | WOBURN | ||||||||
State: | MA | ||||||||
PostalCode: | 01801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7819352655 | ||||||||
FaxNumber: | 7813959097 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2005 | ||||||||
LastUpdateDate: | 08/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILKINSON | ||||||||
AuthorizedOfficialFirstName: | KERRI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER OF CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 6313595589 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225100000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | Y61376 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER |