MEDICARE: PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY 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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1235549452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY PC

Provider Business Mailing Address
First Line	:	576 BROADHOLLOW RD
Second Line	:
City	:	MELVILLE
State	:	NY
Zip	:	11747-5002
Country	:	US
Telephone Number	:	212-226-6704
Fax Number	:	212-226-8207

Provider Business Practice Location Address
First Line	:	552 BROADWAY
Second Line	:	4TH FLOOR
City	:	NEW YORK
State	:	NY
Zip	:	10012-3922
Country	:	US
Telephone Number	:	212-226-6704
Fax Number	:	212-226-8207

Authorized Official
Title or Position	:	VP OF ADMINISTRATIVE OPERATIONS
Name	:	LETICIA PABELLON
Credential	:
Telephone Number	:	516-321-2447

Provider Enumeration Date	:	04/28/2014
Last Update Date	:	03/29/2018

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