Healthcare Provider Details

I. General information

NPI: 1255479119
Provider Name (Legal Business Name): NORTH SHORE PHYSICAL MEDICINE AND REHABILITATION SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 11/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 EXPRESSWAY PLZ STE 110
ROSLYN HEIGHTS NY
11577-2059
US

IV. Provider business mailing address

PO BOX 1357
BAYVILLE NY
11709-0357
US

V. Phone/Fax

Practice location:
  • Phone: 516-621-4062
  • Fax: 516-621-1848
Mailing address:
  • Phone: 516-794-4161
  • Fax: 516-794-9568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number167868-1
License Number StateNY

VIII. Authorized Official

Name: DR. BARRY C. ROOT
Title or Position: OWNER PRESIDENT
Credential: MD
Phone: 516-621-4062