Healthcare Provider Details

I. General information

NPI: 1376719823
Provider Name (Legal Business Name): WESTSIDE SPINE AND SPORTS MEDICINE, P. C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 W 54TH ST 3RD FLOOR
NEW YORK NY
10019-5515
US

IV. Provider business mailing address

244 W 54TH ST 3RD FLOOR
NEW YORK NY
10019-5515
US

V. Phone/Fax

Practice location:
  • Phone: 212-262-7246
  • Fax: 212-262-9178
Mailing address:
  • Phone: 212-262-7246
  • Fax: 212-262-9178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SCOTT REALE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 212-262-7246