=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316927627
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUSION PHYSICAL THERAPY AND SPORTS WELLNESS P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2006
-----------------------------------------------------
Last Update Date | 10/25/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 407 W 13TH ST SUITE 3B
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10014-1112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-924-4920
-----------------------------------------------------
Fax | 212-924-0225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 407 W 13TH ST SUITE 3B
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10014-1112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-924-4920
-----------------------------------------------------
Fax | 212-924-0225
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | CAROLYN S. MAZUR
-----------------------------------------------------
Credential | M.P.T.
-----------------------------------------------------
Telephone | 212-924-4920
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 020721-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------