Provider Demographics
NPI:1124773940
Name:SAMUEL YOO PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:SAMUEL YOO PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:YOO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:646-240-8453
Mailing Address - Street 1:3930 RICHMOND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3930 RICHMOND AVE STE 200
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-5103
Practice Address - Country:US
Practice Address - Phone:718-317-9801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-21
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG400061606OtherMEDICARE MEMBER PTAN FOR QUEENS
NYA400026932OtherMEDICARE MEMBER PTAN FOR BROOKLYN, STATEN ISLAND, MANHATTAN
NY1891939625Medicaid