Healthcare Provider Details

I. General information

NPI: 1154573400
Provider Name (Legal Business Name): PHYSIOCARE PHYSICAL THERAPY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 03/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 W 57TH ST SUITE 1406
NEW YORK NY
10019-2802
US

IV. Provider business mailing address

3270 31ST ST
ASTORIA NY
11106-2643
US

V. Phone/Fax

Practice location:
  • Phone: 212-399-3800
  • Fax: 212-399-3822
Mailing address:
  • Phone: 718-707-6970
  • Fax: 718-732-2864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number011188-1
License Number StateNY

VIII. Authorized Official

Name: DIMITRIOS KOSTOPOULOS
Title or Position: OWNER
Credential: PT, PHD, DSC
Phone: 718-707-6970