Healthcare Provider Details

I. General information

NPI: 1205048139
Provider Name (Legal Business Name): MVP PHYSICAL THERAPY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 PLATINUM CT SUITE B
MEDFORD NY
11763-2247
US

IV. Provider business mailing address

12 PLATINUM CT SUITE B
MEDFORD NY
11763-2247
US

V. Phone/Fax

Practice location:
  • Phone: 631-320-1111
  • Fax: 631-286-6168
Mailing address:
  • Phone: 631-320-1111
  • Fax: 631-286-6168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number015323
License Number StateNY

VIII. Authorized Official

Name: MR. WILLIAM J BROGLIE
Title or Position: OWNER
Credential: P.T.
Phone: 631-320-1111