Healthcare Provider Details

I. General information

NPI: 1295019636
Provider Name (Legal Business Name): MARC S SHEINBLUM DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2011
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL RD SUITE 112
EAST PATCHOGUE NY
11772-8809
US

IV. Provider business mailing address

201 SEMINOLE ST
RONKONKOMA NY
11779-4631
US

V. Phone/Fax

Practice location:
  • Phone: 631-456-5512
  • Fax: 631-456-5514
Mailing address:
  • Phone: 631-456-5512
  • Fax: 631-456-5514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number034220-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: