Healthcare Provider Details

I. General information

NPI: 1114255791
Provider Name (Legal Business Name): PREMIER MEDICAL FOR SPORT & REHABILITATION, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2009
Last Update Date: 11/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11027 72ND DR
FOREST HILLS NY
11375-5513
US

IV. Provider business mailing address

PO BOX 290707
BROOKLYN NY
11229-0707
US

V. Phone/Fax

Practice location:
  • Phone: 718-258-7203
  • Fax: 718-258-7202
Mailing address:
  • Phone: 718-258-7203
  • Fax: 718-258-7202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number199870
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number199870
License Number StateNY

VIII. Authorized Official

Name: DR. AHMED E. ELEMAM
Title or Position: OWNER
Credential: M.D.
Phone: 718-258-7203