MEDICARE: MR. JACK D. WEINSTOCK RPT

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	225100000X	Physical Therapist	3179	NY

General Provider Information

NPI Number	:	1346251006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK D. WEINSTOCK RPT

Provider Business Mailing Address
First Line	:	347 5TH AVE RM 410
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10016-5010
Country	:	US
Telephone Number	:	212-725-3778
Fax Number	:	347-273-1086

Provider Business Practice Location Address
First Line	:	347 5TH AVE RM 410
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10016-5010
Country	:	US
Telephone Number	:	212-725-3778
Fax Number	:	347-273-1086

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	07/08/2007

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