Provider Demographics
NPI:1285958595
Name:POREMBA, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:POREMBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MAVERICK TER
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:NY
Mailing Address - Zip Code:12498-1723
Mailing Address - Country:US
Mailing Address - Phone:845-679-7643
Mailing Address - Fax:845-679-7643
Practice Address - Street 1:17 MAVERICK TER
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:NY
Practice Address - Zip Code:12498-1723
Practice Address - Country:US
Practice Address - Phone:845-679-7643
Practice Address - Fax:845-679-7643
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024821-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY225100000XOtherPHYSICAL THERAPY OUTPATIENT