MEDICARE: DEKHTYAREV 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	320700000X	Physical Disabilities Residential Treatment Facility	030526	NY

General Provider Information

NPI Number	:	1508099417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEKHTYAREV PHYSICAL THERAPY PC

Provider Business Mailing Address
First Line	:	2044 E 18TH ST APT 2F
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-3836
Country	:	US
Telephone Number	:	917-538-5175
Fax Number	:

Provider Business Practice Location Address
First Line	:	1811 QUENTIN RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-1343
Country	:	US
Telephone Number	:	917-538-5175
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ALEKSANDR DEKHTYAREV
Credential	:	DPT
Telephone Number	:	19175385175

Provider Enumeration Date	:	08/26/2009
Last Update Date	:	08/26/2009

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