=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649874405
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHISHKIN PHYSICAL THERAPY REHAB PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2020
-----------------------------------------------------
Last Update Date | 11/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 E BROADWAY FL 3
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10002-7037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-233-0889
-----------------------------------------------------
Fax | 212-233-0898
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7945 GRAND AVE FL 2
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11373-4129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-320-0155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PT
-----------------------------------------------------
Name | DR. THEDA SHISHKIN
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 347-320-0155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------