Healthcare Provider Details

I. General information

NPI: 1609906114
Provider Name (Legal Business Name): 42ND STREET PHYSICAL MEDICINE & REHABILITAION,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E 42ND ST 5TH FLOOR
NEW YORK NY
10017-5678
US

IV. Provider business mailing address

120 E 42ND ST 5TH FLOOR
NEW YORK NY
10017-5678
US

V. Phone/Fax

Practice location:
  • Phone: 212-370-5551
  • Fax: 212-370-5559
Mailing address:
  • Phone: 212-370-5551
  • Fax: 212-370-5559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number203547
License Number StateNY

VIII. Authorized Official

Name: DR. RICHARD KOFFLER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 212-370-5551