MEDICARE: AMG IMPACT REHAB PT PC

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	:	1194560425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMG IMPACT REHAB PT PC

Provider Business Mailing Address
First Line	:	412 PROSPECT AVE
Second Line	:
City	:	DUMONT
State	:	NJ
Zip	:	07628-1404
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 PELHAM PKWY S
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10461-1001
Country	:	US
Telephone Number	:	718-682-3152
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	AHMED GHANEM
Credential	:
Telephone Number	:	347-459-8493

Provider Enumeration Date	:	06/27/2024
Last Update Date	:	06/27/2024

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