Provider Demographics
NPI:1306266721
Name:LIBERTY PHYSICAL MEDICINE AND REHABILITATION, P.C.
Entity type:Organization
Organization Name:LIBERTY PHYSICAL MEDICINE AND REHABILITATION, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-651-8414
Mailing Address - Street 1:4037 81ST ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1393
Mailing Address - Country:US
Mailing Address - Phone:718-651-8414
Mailing Address - Fax:718-651-8413
Practice Address - Street 1:4037 81ST ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1393
Practice Address - Country:US
Practice Address - Phone:718-651-8414
Practice Address - Fax:718-651-8413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYA2414421261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1154401883OtherNPI TYPE 1
NY07852Medicare UPIN