MEDICARE: STAY ACTIVE PHYSICAL THERAPY, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0444489	OTHER	NY	UNIVERSITY OF THE STATE OF NEW YORK, PHYSICAL THERAPIST

General Provider Information

NPI Number	:	1003441098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STAY ACTIVE PHYSICAL THERAPY, PLLC

Provider Business Mailing Address
First Line	:	9322 3RD AVE STE 476
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-6802
Country	:	US
Telephone Number	:	917-915-3894
Fax Number	:

Provider Business Practice Location Address
First Line	:	297 BAY 20TH ST APT 2
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-6011
Country	:	US
Telephone Number	:	917-915-3894
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ALEXANDER AKSANOV
Credential	:	DPT
Telephone Number	:	917-915-3894

Provider Enumeration Date	:	03/10/2020
Last Update Date	:	03/10/2020

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