Healthcare Provider Details

I. General information

NPI: 1760043715
Provider Name (Legal Business Name): INTERVENTIONAL PHYSICAL MEDICINE AND REHAB OF NEW YORK, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 11/04/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 NORTHERN BLVD GR 1
MANHASSET NY
11030
US

IV. Provider business mailing address

8 SUMTER AVE
EAST WILLISTON NY
11596-2433
US

V. Phone/Fax

Practice location:
  • Phone: 516-888-7614
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
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: TERESA RIVERA
Title or Position: OFFICE MANAGER
Credential:
Phone: 516-888-7614