MEDICARE: TATI B HARSONO P.T.

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	021060-1	NY

General Provider Information

NPI Number	:	1407152622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TATI B HARSONO P.T.

Provider Business Mailing Address
First Line	:	384 CEDAR AVE
Second Line	:
City	:	RIDGEWOOD
State	:	NJ
Zip	:	07450-5112
Country	:	US
Telephone Number	:	347-424-9686
Fax Number	:	646-861-5926

Provider Business Practice Location Address
First Line	:	500 BI COUNTY BLVD
Second Line	:	SUITE 210N
City	:	FARMINGDALE
State	:	NY
Zip	:	11735-3988
Country	:	US
Telephone Number	:	718-264-1640
Fax Number	:

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

Provider Enumeration Date	:	02/04/2011
Last Update Date	:	02/04/2011

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