=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134350630
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAIN STREET PHYSICAL THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2009
-----------------------------------------------------
Last Update Date | 05/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 51 FARREL ST
-----------------------------------------------------
City | NEW HYDE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11040-2407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-850-1285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 51 FARREL ST
-----------------------------------------------------
City | NEW HYDE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11040-2407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-850-1285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. VENKATESAN SIVARAMAN
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 516-850-1285
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 017069-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------