Provider Demographics
NPI:1043316318
Name:EAST END PHYSICAL THERAPY, PC
Entity type:Organization
Organization Name:EAST END PHYSICAL THERAPY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:FAYE
Authorized Official - Middle Name:H
Authorized Official - Last Name:MCDEW
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:631-298-2041
Mailing Address - Street 1:PO BOX 1553
Mailing Address - Street 2:
Mailing Address - City:MATTITUCK
Mailing Address - State:NY
Mailing Address - Zip Code:11952
Mailing Address - Country:US
Mailing Address - Phone:631-298-2041
Mailing Address - Fax:631-298-1362
Practice Address - Street 1:7905 MAIN RD
Practice Address - Street 2:
Practice Address - City:MATTITUCK
Practice Address - State:NY
Practice Address - Zip Code:11952-0902
Practice Address - Country:US
Practice Address - Phone:631-298-2041
Practice Address - Fax:631-298-1362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0047041225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ59881Medicare PIN