=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366935397
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACTION MEDICAL AND REHAB PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2018
-----------------------------------------------------
Last Update Date | 06/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3400 NESCONSET HWY STE 104
-----------------------------------------------------
City | EAST SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11733-3327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-898-6626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 665 TREEHOUSE CIR
-----------------------------------------------------
City | SAINT AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32095-6837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-654-2410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. EDWARD TANZA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-654-2410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------