MEDICARE: PLATINUM WELLNESS PHYSICAL THERAPY, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	A300000048	OTHER		MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1770535379	OTHER	NY	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1174767958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLATINUM WELLNESS PHYSICAL THERAPY, P.C.

Provider Business Mailing Address
First Line	:	400 E 74TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10021-3912
Country	:	US
Telephone Number	:	212-452-2400
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 E 74TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10021-3912
Country	:	US
Telephone Number	:	212-452-2400
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SHARI ROSEN
Credential	:	P.T.
Telephone Number	:	212-452-2400

Provider Enumeration Date	:	04/24/2009
Last Update Date	:	04/24/2009

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