MEDICARE: MR. HUGO PETER VAN DIJK PT, MBA

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	174400000X	Specialist	015788	NY

General Provider Information

NPI Number	:	1316186844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HUGO PETER VAN DIJK PT, MBA

Provider Business Mailing Address
First Line	:	215 SHORE RD
Second Line	:	APARTMENT 4
City	:	LONG BEACH
State	:	NY
Zip	:	11561-4257
Country	:	US
Telephone Number	:	718-440-1979
Fax Number	:

Provider Business Practice Location Address
First Line	:	215 SHORE RD
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-4257
Country	:	US
Telephone Number	:	718-440-1979
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2009
Last Update Date	:	03/18/2013

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