=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457496291
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MADISON AVENUE PHYSICAL THERAPY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1015 MADISON AVE SUITE 303
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10021-0261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-772-6610
-----------------------------------------------------
Fax | 212-772-7804
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1015 MADISON AVE SUITE 303
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10021-0261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-772-6610
-----------------------------------------------------
Fax | 212-772-7804
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. TZVI BARAK
-----------------------------------------------------
Credential | P.T., PH.D, OCS
-----------------------------------------------------
Telephone | 212-772-6610
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 003127-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 001915
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------