Healthcare Provider Details

I. General information

NPI: 1528191830
Provider Name (Legal Business Name): PHYSICAL MEDICINE AND REHABILITATION OF NY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 PUTNAM AVE W
BRONX NY
10463-2442
US

IV. Provider business mailing address

9520 QUEENS BLVD
REGO PARK NY
11374-1136
US

V. Phone/Fax

Practice location:
  • Phone: 718-549-7260
  • Fax:
Mailing address:
  • Phone: 718-459-1280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number218201
License Number StateNY

VIII. Authorized Official

Name: DR. GAUTAM KAUSHIK KHAKHAR
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 718-549-7260