MEDICARE: NEW YORK SPORT & REHABILITATION MEDICINE 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	208100000X	Physical Medicine & Rehabilitation Physician	238359	NY

General Provider Information

NPI Number	:	1548443351
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW YORK SPORT & REHABILITATION MEDICINE PC

Provider Business Mailing Address
First Line	:	140 MIDDLE NECK RD
Second Line	:
City	:	GREAT NECK
State	:	NY
Zip	:	11021-1246
Country	:	US
Telephone Number	:	516-829-3399
Fax Number	:	516-829-9500

Provider Business Practice Location Address
First Line	:	140 MIDDLE NECK RD
Second Line	:
City	:	GREAT NECK
State	:	NY
Zip	:	11021-1246
Country	:	US
Telephone Number	:	516-829-3399
Fax Number	:	516-829-9500

Authorized Official
Title or Position	:	OWNER
Name	:	KIOOMARS MOOSAZADEH
Credential	:	MD
Telephone Number	:	516-829-3399

Provider Enumeration Date	:	12/14/2007
Last Update Date	:	02/05/2020

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