MEDICARE: PREMIER PT LIMITED LIABILITY COMP

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	40QA00915800	NJ

General Provider Information

NPI Number	:	1205235595
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER PT LIMITED LIABILITY COMP

Provider Business Mailing Address
First Line	:	788 MORRIS TPKE STE 301
Second Line	:
City	:	SHORT HILLS
State	:	NJ
Zip	:	07078-2634
Country	:	US
Telephone Number	:	973-467-4444
Fax Number	:	973-467-4446

Provider Business Practice Location Address
First Line	:	788 MORRIS TPKE STE 301
Second Line	:
City	:	SHORT HILLS
State	:	NJ
Zip	:	07078-2634
Country	:	US
Telephone Number	:	973-467-4444
Fax Number	:	973-467-4446

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	MR. DOUGLAS D BENSON
Credential	:	P.T.
Telephone Number	:	973-467-4444

Provider Enumeration Date	:	08/22/2014
Last Update Date	:	07/22/2022

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