MEDICARE: RESURGENCE PHYSICAL THERAPY LLC

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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1144719188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESURGENCE PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	30 FARRAND ST APT 530
Second Line	:
City	:	BLOOMFIELD
State	:	NJ
Zip	:	07003-4439
Country	:	US
Telephone Number	:	585-322-5434
Fax Number	:

Provider Business Practice Location Address
First Line	:	561 BLOOMFIELD AVE
Second Line	:
City	:	VERONA
State	:	NJ
Zip	:	07044-1818
Country	:	US
Telephone Number	:	973-744-6279
Fax Number	:	973-200-2252

Authorized Official
Title or Position	:	OWNER/PHYSICAL THERAPIST
Name	:	DR. RYAN GOODELL
Credential	:	DPT
Telephone Number	:	585-322-5434

Provider Enumeration Date	:	05/04/2018
Last Update Date	:	03/15/2022

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