=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518785344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE AZURE PHYSICAL THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2024
-----------------------------------------------------
Last Update Date | 10/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11508 150TH AVE
-----------------------------------------------------
City | SOUTH OZONE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11420-3909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-899-3055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11508 150TH AVE
-----------------------------------------------------
City | SOUTH OZONE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11420-3909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-899-3055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ PRESIDENT
-----------------------------------------------------
Name | EHAB A HAFEZ
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 929-899-3055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------