Healthcare Provider Details

I. General information

NPI: 1174343305
Provider Name (Legal Business Name): ALEXANDER EBERENZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 10/14/2024
Certification Date: 10/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 PROSPECT ST
HUNTINGTON NY
11743-3318
US

IV. Provider business mailing address

38 PHIPPS LN
PLAINVIEW NY
11803-1948
US

V. Phone/Fax

Practice location:
  • Phone: 631-629-1261
  • Fax:
Mailing address:
  • Phone: 516-474-0359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number049390
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: