Healthcare Provider Details

I. General information

NPI: 1245786037
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: 08/31/2016
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1069 RINGWOOD AVE
HASKELL NJ
07420-1408
US

IV. Provider business mailing address

576 BROADHOLLOW RD
MELVILLE NY
11747-5002
US

V. Phone/Fax

Practice location:
  • Phone: 973-616-9700
  • Fax: 973-616-9790
Mailing address:
  • Phone: 631-359-5859
  • Fax: 631-396-0865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: KATHLEEN BRUSH
Title or Position: CREDENTIALING COORDINATOR MANAGER
Credential:
Phone: 631-359-5859