MEDICARE: BACK IN THE GAME WELLNESS PHYSICAL 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	208100000X	Physical Medicine & Rehabilitation Physician
2	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1518486257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK IN THE GAME WELLNESS PHYSICAL THERAPY, PLLC

Provider Business Mailing Address
First Line	:	575 LEXINGTON AVE FL 4
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-6146
Country	:	US
Telephone Number	:	646-286-7140
Fax Number	:

Provider Business Practice Location Address
First Line	:	575 LEXINGTON AVE FL 4
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-6146
Country	:	US
Telephone Number	:	646-286-7140
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MONICA JOSHI
Credential	:
Telephone Number	:	646-286-7140

Provider Enumeration Date	:	09/13/2017
Last Update Date	:	03/31/2021

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