MEDICARE: EMMETT VAN SLYKE D.P.T.

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	039289	NY
2	225100000X	Physical Therapist	P97662	NY

General Provider Information

NPI Number	:	1366824617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMETT VAN SLYKE D.P.T.

Provider Business Mailing Address
First Line	:	1841 BROADWAY RM 500
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10023-7685
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1841 BROADWAY RM 500
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10023-7685
Country	:	US
Telephone Number	:	212-245-5500
Fax Number	:

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

Provider Enumeration Date	:	06/23/2015
Last Update Date	:	04/05/2016

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Directions to “ EMMETT VAN SLYKE D.P.T.” Practice Location

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