MEDICARE: PROFESSIONAL ORTHOPEDIC & SPORTS PT

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	012833	NY

General Provider Information

NPI Number	:	1801913330
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL ORTHOPEDIC & SPORTS PT

Provider Business Mailing Address
First Line	:	576 BROADHOLLOW RD
Second Line	:
City	:	MELVILLE
State	:	NY
Zip	:	11747-5002
Country	:	US
Telephone Number	:	631-359-5800
Fax Number	:	631-396-0865

Provider Business Practice Location Address
First Line	:	54 MURRAY ST
Second Line	:	EQUINOX
City	:	NEW YORK
State	:	NY
Zip	:	10007-2219
Country	:	US
Telephone Number	:	212-453-4622
Fax Number	:	212-453-4621

Authorized Official
Title or Position	:	REGIONAL BUSINESS MANAGER
Name	:	MRS. KATHLEEN BRUSH
Credential	:
Telephone Number	:	631-359-5805

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	03/29/2018

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