Healthcare Provider Details

I. General information

NPI: 1336674613
Provider Name (Legal Business Name): SAMUEL J MIN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2017
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COMMERCE WAY STE C
HACKENSACK NJ
07601-6307
US

IV. Provider business mailing address

845 BROAD AVE
RIDGEFIELD NJ
07657-1002
US

V. Phone/Fax

Practice location:
  • Phone: 201-300-4447
  • Fax:
Mailing address:
  • Phone: 201-840-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01655400
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: