=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407317761
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW ROMANOFF
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2019
-----------------------------------------------------
Last Update Date | 03/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 SOUTH ST STE 110
-----------------------------------------------------
City | OYSTER BAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11771-2274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-624-6739
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 268 LINDBERG ST
-----------------------------------------------------
City | WEST HEMPSTEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11552-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-587-0387
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 036331
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------