Provider Demographics
NPI:1609280353
Name:BAHLOUL, AMGED SR (PT)
Entity type:Individual
Prefix:MR
First Name:AMGED
Middle Name:
Last Name:BAHLOUL
Suffix:SR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 BELAIR LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3066
Mailing Address - Country:US
Mailing Address - Phone:917-696-0679
Mailing Address - Fax:718-442-2688
Practice Address - Street 1:23 BELAIR LN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3066
Practice Address - Country:US
Practice Address - Phone:917-696-0679
Practice Address - Fax:718-442-2688
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017131-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist