Healthcare Provider Details

I. General information

NPI: 1811061252
Provider Name (Legal Business Name): CRESCENT DIAGNOSTIC PREVENTIVE & REHABLITATION MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2006
Last Update Date: 10/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 HEYWOOD ST
NEW HYDE PARK NY
11040-2412
US

IV. Provider business mailing address

52 HEYWOOD ST
NEW HYDE PARK NY
11040-2412
US

V. Phone/Fax

Practice location:
  • Phone: 718-339-8950
  • Fax: 718-339-8953
Mailing address:
  • Phone: 718-339-8950
  • Fax: 718-339-8953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number211161
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number211161
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number211161
License Number StateNY

VIII. Authorized Official

Name: DR. ABU TAHER
Title or Position: PRESIDENT
Credential: MD
Phone: 718-339-8950