Healthcare Provider Details

I. General information

NPI: 1528351988
Provider Name (Legal Business Name): PREMIER PHYSICAL THERAPY OF LONG ISLAND PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2011
Last Update Date: 05/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TERRY ST
PATCHOGUE NY
11772-1720
US

IV. Provider business mailing address

84 PACIFIC BLVD
LONG BEACH NY
11561-4700
US

V. Phone/Fax

Practice location:
  • Phone: 111-111-1111
  • Fax:
Mailing address:
  • Phone: 516-698-2930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number024794
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MATTHEW DAVID ANGELILLO
Title or Position: DIRECTOR
Credential: DPT
Phone: 111-111-1111