MEDICARE: DEREK J MC CONNELL P.T.

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	174400000X	Specialist	40QA01449100	NJ

General Provider Information

NPI Number	:	1861837742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK J MC CONNELL P.T.

Provider Business Mailing Address
First Line	:	576 BROADHOLLOW RD
Second Line	:
City	:	MELVILLE
State	:	NY
Zip	:	11747-5002
Country	:	US
Telephone Number	:	631-359-5859
Fax Number	:

Provider Business Practice Location Address
First Line	:	1325 WARREN AVE
Second Line	:
City	:	SPRING LAKE
State	:	NJ
Zip	:	07762-2566
Country	:	US
Telephone Number	:	732-449-7855
Fax Number	:	732-449-7856

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

Provider Enumeration Date	:	05/06/2013
Last Update Date	:	12/18/2020

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