MEDICARE: BASEM MANSOUR

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	038815	NY

General Provider Information

NPI Number	:	1760851398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BASEM MANSOUR

Provider Business Mailing Address
First Line	:	10 BONNIE DR
Second Line	:
City	:	NORTH MIDDLETOWN
State	:	NJ
Zip	:	07748-5108
Country	:	US
Telephone Number	:	732-533-7330
Fax Number	:

Provider Business Practice Location Address
First Line	:	5607 AVENUE L
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-3317
Country	:	US
Telephone Number	:	718-758-5220
Fax Number	:	718-758-5260

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

Provider Enumeration Date	:	09/24/2015
Last Update Date	:	09/24/2015

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Directions to “ BASEM MANSOUR ” Practice Location

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