Basic Information
| Provider Information | |||||||||
| NPI: | 1932645181 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2142 UTOPIA PKWY | ||||||||
| Address2: | |||||||||
| City: | WHITESTONE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113574142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188196805 | ||||||||
| FaxNumber: | 3478419109 | ||||||||
| Practice Location | |||||||||
| Address1: | 279 SUNRISE HWY | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE CENTRE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115704925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162554263 | ||||||||
| FaxNumber: | 5162554050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2017 | ||||||||
| LastUpdateDate: | 01/12/2017 | ||||||||
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| AuthorizedOfficialLastName: | BRUSH | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7188196805 | ||||||||
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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.