MEDICARE: SOURCE OF 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	208100000X	Physical Medicine & Rehabilitation Physician	025885	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619317815
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOURCE OF PHYSICAL THERAPY PC

Provider Business Mailing Address
First Line	:	4051 JUNCTION BLVD FL 2
Second Line	:
City	:	CORONA
State	:	NY
Zip	:	11368-2121
Country	:	US
Telephone Number	:	718-880-8468
Fax Number	:

Provider Business Practice Location Address
First Line	:	4051 JUNCTION BLVD FL 2
Second Line	:
City	:	CORONA
State	:	NY
Zip	:	11368-2121
Country	:	US
Telephone Number	:	718-880-8468
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. MARGARITA MUGURUZA
Credential	:	PT
Telephone Number	:	718-880-8468

Provider Enumeration Date	:	07/02/2013
Last Update Date	:	07/02/2013

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