MEDICARE: MITU PHYSICAL THERAPY PC

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	0184751	NY

General Provider Information

NPI Number	:	1376051102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MITU PHYSICAL THERAPY PC

Provider Business Mailing Address
First Line	:	3728 75TH ST LOWR LEVEL
Second Line	:
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372-6426
Country	:	US
Telephone Number	:	718-205-7710
Fax Number	:

Provider Business Practice Location Address
First Line	:	421 78TH ST STE C
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-3447
Country	:	US
Telephone Number	:	718-205-7710
Fax Number	:

Authorized Official
Title or Position	:	RPT
Name	:	NAGAH ALAIDY
Credential	:	RPT
Telephone Number	:	718-205-7710

Provider Enumeration Date	:	01/15/2018
Last Update Date	:	01/15/2018

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