MEDICARE: PARK SPORTS PHYSICAL THERAPY AND PARK SLOPE OCCUPATIONAL THERAPY PLLC

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	225X00000X	Occupational Therapist	013213	NY
2	225100000X	Physical Therapist	011045	NY

General Provider Information

NPI Number	:	1194984799
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK SPORTS PHYSICAL THERAPY AND PARK SLOPE OCCUPATIONAL THERAPY PLLC

Provider Business Mailing Address
First Line	:	670 6TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11215-6316
Country	:	US
Telephone Number	:	718-369-2560
Fax Number	:

Provider Business Practice Location Address
First Line	:	670 6TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11215-6316
Country	:	US
Telephone Number	:	718-369-2560
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BORIS GILZON
Credential	:	PT CHT
Telephone Number	:	718-369-2560

Provider Enumeration Date	:	06/09/2008
Last Update Date	:	06/09/2008

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