Healthcare Provider Details

I. General information

NPI: 1902531593
Provider Name (Legal Business Name): PHILIP RYDER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

596 CENTER BRIARWOOD AVE
WEST ISLIP NY
11795-4004
US

IV. Provider business mailing address

596 CENTER BRIARWOOD AVE
WEST ISLIP NY
11795-4004
US

V. Phone/Fax

Practice location:
  • Phone: 191-449-7291
  • Fax:
Mailing address:
  • Phone: 191-449-7291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number002240
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: