MEDICARE: OMEGA 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	320700000X	Physical Disabilities Residential Treatment Facility	020632	NY

General Provider Information

NPI Number	:	1578798534
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMEGA PHYSICAL THERAPY,PC

Provider Business Mailing Address
First Line	:	2327 83RD ST STE C
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-2749
Country	:	US
Telephone Number	:	718-996-9929
Fax Number	:	718-265-1807

Provider Business Practice Location Address
First Line	:	2327 83RD ST STE C
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-2749
Country	:	US
Telephone Number	:	718-996-9929
Fax Number	:	718-265-1807

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DMITRY SHESTAKOVSKY
Credential	:	DPT
Telephone Number	:	718-996-9929

Provider Enumeration Date	:	05/20/2009
Last Update Date	:	02/16/2012

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