Healthcare Provider Details

I. General information

NPI: 1376951889
Provider Name (Legal Business Name): PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF NJ, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 OLD HOOK RD
EMERSON NJ
07630-2302
US

IV. Provider business mailing address

576 BROADHOLLOW RD
MELVILLE NY
11747-5002
US

V. Phone/Fax

Practice location:
  • Phone: 201-497-6752
  • Fax: 201-497-6756
Mailing address:
  • Phone: 516-321-2400
  • Fax: 516-321-2401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MS. KATHLEEN BRUSH
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 718-819-6805