=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366233124
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYU ANDRE MARCUS PRIMERO PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2025
-----------------------------------------------------
Last Update Date | 06/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 332 E 34TH ST, 1E
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-651-4380
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 72-38 113TH STREET, APT 4B FOREST HILLS
-----------------------------------------------------
City | NEW YORK CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-249-1601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 050685
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------