=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366683054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOLA PHYSICAL THERAPY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2009
-----------------------------------------------------
Last Update Date | 03/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 W 45TH ST STE 208
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10036-4268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-840-6652
-----------------------------------------------------
Fax | 212-840-6022
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 W 45TH ST STE 208
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10036-4268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-840-6652
-----------------------------------------------------
Fax | 212-840-6022
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST, OWNER
-----------------------------------------------------
Name | JASON GROMELSKI
-----------------------------------------------------
Credential | PT, MPT, ATC-L, CSCS
-----------------------------------------------------
Telephone | 212-840-6652
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 022090-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------