=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740455633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROM ON THE RUN PHYSICAL THERAPY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2008
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 290 LARKFIELD RD UNIT B
-----------------------------------------------------
City | EAST NORTHPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11731-2444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-547-5500
-----------------------------------------------------
Fax | 631-427-2223
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 290 LARKFIELD RD UNIT B
-----------------------------------------------------
City | EAST NORTHPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11731-2444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-547-5500
-----------------------------------------------------
Fax | 631-427-2223
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DAVID W FISCHER
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 631-547-5500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 012591-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 012591-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------