MEDICARE: LONG ISLAND CITY PHYSICAL THERAPY, PLLC

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	022838-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11452885	OTHER	NY	CAQH PROVIDER ID

General Provider Information

NPI Number	:	1699871780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONG ISLAND CITY PHYSICAL THERAPY, PLLC

Provider Business Mailing Address
First Line	:	1043 48TH AVE
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-5607
Country	:	US
Telephone Number	:	718-943-7100
Fax Number	:	718-786-9798

Provider Business Practice Location Address
First Line	:	1043 48TH AVE
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-5607
Country	:	US
Telephone Number	:	718-943-7100
Fax Number	:	718-786-9798

Authorized Official
Title or Position	:	DIRECTOR PHYSICAL THERAPY
Name	:	MS. PATRICIA ANN BRANCALE
Credential	:	M.S.P.T.
Telephone Number	:	718-943-7100

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	03/22/2010

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