MEDICARE: NY PROFORM 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	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	025663	OTHER	NY	STATE LICENSE

General Provider Information

NPI Number	:	1790328037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NY PROFORM PHYSICAL THERAPY PC

Provider Business Mailing Address
First Line	:	9522 63RD RD
Second Line	:
City	:	REGO PARK
State	:	NY
Zip	:	11374-1142
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3350 WHITE PLAINS RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10467-5701
Country	:	US
Telephone Number	:	718-618-0052
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SAM HANNA
Credential	:	PT
Telephone Number	:	718-618-0052

Provider Enumeration Date	:	10/18/2019
Last Update Date	:	10/18/2019

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