Healthcare Provider Details

I. General information

NPI: 1538361100
Provider Name (Legal Business Name): KEVIN H LYSAGHT PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WALT WHITMAN RD SUITE 310
MELVILLE NY
11747-2293
US

IV. Provider business mailing address

71 BANKSIDE DR
CENTERPORT NY
11721-1738
US

V. Phone/Fax

Practice location:
  • Phone: 631-923-2288
  • Fax: 631-714-6142
Mailing address:
  • Phone: 631-996-2420
  • Fax: 631-714-6142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number021743-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: