MEDICARE: PROFESSIONAL ORTHOPEDIC AND SPORTS 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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1598256539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY PC

Provider Business Mailing Address
First Line	:	576 BROADHOLLOW RD
Second Line	:
City	:	MELVILLE
State	:	NY
Zip	:	11747-5002
Country	:	US
Telephone Number	:	631-359-5859
Fax Number	:	631-396-0865

Provider Business Practice Location Address
First Line	:	599 GRAMATAN AVE STE 205
Second Line	:
City	:	FLEETWOOD
State	:	NY
Zip	:	10552
Country	:	US
Telephone Number	:	914-371-1990
Fax Number	:	914-371-7588

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	KATHLEEN BRUSH
Credential	:
Telephone Number	:	631-359-5805

Provider Enumeration Date	:	05/25/2018
Last Update Date	:	05/30/2018

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