Basic Information
| Provider Information | |||||||||
| NPI: | 1841716339 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 576 BROADHOLLOW RD | ||||||||
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| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117475002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313595859 | ||||||||
| FaxNumber: | 6313960865 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 DURHAM AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH PLAINFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070802504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082058625 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2017 | ||||||||
| LastUpdateDate: | 04/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | BRUSH | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6313595859 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.