MEDICARE: PHANI JAYA SREE KAZA 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	032443	NY

General Provider Information

NPI Number	:	1871883249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHANI JAYA SREE KAZA PT

Provider Business Mailing Address
First Line	:	1904 VILLAGE DR
Second Line	:
City	:	AVENEL
State	:	NJ
Zip	:	07001-1048
Country	:	US
Telephone Number	:	916-753-4534
Fax Number	:

Provider Business Practice Location Address
First Line	:	260 MIDDLE COUNTRY RD
Second Line	:	BLDG.3, SUITE 9-A
City	:	SELDEN
State	:	NY
Zip	:	11784-2568
Country	:	US
Telephone Number	:	631-732-1600
Fax Number	:	631-732-7872

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

Provider Enumeration Date	:	04/19/2011
Last Update Date	:	04/19/2011

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