Basic Information
Provider Information | |||||||||
NPI: | 1891291076 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF N.J., L.L.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
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Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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Mailing Information | |||||||||
Address1: | 576 BROADHOLLOW RD | ||||||||
Address2: |   | ||||||||
City: | MELVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 117475002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6313595800 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7 CEDAR GROVE LN STE 9 | ||||||||
Address2: |   | ||||||||
City: | SOMERSET | ||||||||
State: | NJ | ||||||||
PostalCode: | 088731331 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7324695680 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/05/2018 | ||||||||
LastUpdateDate: | 04/05/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRUSH | ||||||||
AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6313595805 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, P.C. | ||||||||
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NPICertificationDate: |   |
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.