Healthcare Provider Details

I. General information

NPI: 1548814742
Provider Name (Legal Business Name): EVOLVE PHYSICAL MEDICINE AND REHABILITATION, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 BROADWAY STE 2403
NEW YORK NY
10018-1905
US

IV. Provider business mailing address

1441 BROADWAY STE 2403
NEW YORK NY
10018-1905
US

V. Phone/Fax

Practice location:
  • Phone: 212-404-8032
  • Fax:
Mailing address:
  • Phone: 212-404-8032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANA BELLO
Title or Position: INSURANCE RESOLUTION SPECIALIST
Credential:
Phone: 212-404-7355