MEDICARE: BRICK-RUN SPORTS 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	225100000X	Physical Therapist	022056	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	QN5751	OTHER	NY	BCBS

General Provider Information

NPI Number	:	1821304791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRICK-RUN SPORTS PHYSICAL THERAPY PLLC

Provider Business Mailing Address
First Line	:	730 COLUMBUS AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10025-6658
Country	:	US
Telephone Number	:	212-665-5070
Fax Number	:	212-665-5077

Provider Business Practice Location Address
First Line	:	730 COLUMBUS AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10025-6658
Country	:	US
Telephone Number	:	212-665-5070
Fax Number	:	212-665-5077

Authorized Official
Title or Position	:	OWNER
Name	:	GURJEET CHADHA
Credential	:	DPT
Telephone Number	:	212-665-5070

Provider Enumeration Date	:	08/29/2010
Last Update Date	:	11/30/2010

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