Healthcare Provider Details

I. General information

NPI: 1639695398
Provider Name (Legal Business Name): MODERN MOVEMENT PHYSICAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2017
Last Update Date: 04/08/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18017 GAWTHROP DR
BRADENTON FL
34211
US

IV. Provider business mailing address

8429 LORRAINE RD # 127
LAKEWOOD RANCH FL
34202-9010
US

V. Phone/Fax

Practice location:
  • Phone: 917-416-2209
  • Fax:
Mailing address:
  • Phone: 917-416-2209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number031866
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number031866
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: EUGENE BARSHAY
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 917-416-2209