Provider Demographics
NPI:1285922377
Name:THE PHYSICAL MEDICINE CLINIC LLC
Entity type:Organization
Organization Name:THE PHYSICAL MEDICINE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MITRUSKA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:732-324-4300
Mailing Address - Street 1:788 CONVERY BLVD
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-2584
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:453 AMBOY AVE
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095-2960
Practice Address - Country:US
Practice Address - Phone:732-324-4300
Practice Address - Fax:732-324-8211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-11
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty