=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699287789
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REARDON PHYSICAL THERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2017
-----------------------------------------------------
Last Update Date | 10/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 CEDAR AVE
-----------------------------------------------------
City | ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11751-3802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-647-0523
-----------------------------------------------------
Fax | 631-870-0294
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 HANCOCK RD
-----------------------------------------------------
City | WEST ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11795-1738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-926-5907
-----------------------------------------------------
Fax | 631-926-5907
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GREGORY REARDON
-----------------------------------------------------
Credential | DPT, CSCS
-----------------------------------------------------
Telephone | 631-647-0523
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 036545
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------