Healthcare Provider Details

I. General information

NPI: 1861715831
Provider Name (Legal Business Name): ACTIVE EAST PHYSICAL THERAPY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2010
Last Update Date: 04/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 MAJORS PATH SUITE A
SOUTHAMPTON NY
11968-2431
US

IV. Provider business mailing address

PO BOX 967
SOUTHAMPTON NY
11969-0967
US

V. Phone/Fax

Practice location:
  • Phone: 631-377-3488
  • Fax:
Mailing address:
  • Phone: 631-377-3488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number0163951
License Number StateNY

VIII. Authorized Official

Name: MATTHEW P MOBIUS
Title or Position: OWNER
Credential: PT
Phone: 631-377-3488