=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487794640
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONG ISLAND PHYSICAL REHABILITATION & SPORTS MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 444 LAKEVILLE RD SUITE 201
-----------------------------------------------------
City | NEW HYDE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11042-1165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-326-1950
-----------------------------------------------------
Fax | 516-326-2950
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 444 LAKEVILLE RD SUITE 201
-----------------------------------------------------
City | NEW HYDE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11042-1165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-326-1950
-----------------------------------------------------
Fax | 516-326-2950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MONTE A HABER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 516-326-1950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 191224
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------