MEDICARE: PRIME PHYSIQUE PHYSICAL THERAPY

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	030276	NY

General Provider Information

NPI Number	:	1114275682
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME PHYSIQUE PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	229 JEFFERSON AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11216-1708
Country	:	US
Telephone Number	:	917-805-7031
Fax Number	:	718-679-9214

Provider Business Practice Location Address
First Line	:	229 JEFFERSON AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11216-1708
Country	:	US
Telephone Number	:	917-805-7031
Fax Number	:	718-679-9214

Authorized Official
Title or Position	:	PRESIDENT; DOCTOR OF PT
Name	:	KAREN THERNELAN
Credential	:	D.P.T
Telephone Number	:	917-805-7031

Provider Enumeration Date	:	08/15/2012
Last Update Date	:	08/15/2012

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