Provider Demographics
NPI:1366565616
Name:IMRAN, MUHAMMAD (PT)
Entity type:Individual
Prefix:MR
First Name:MUHAMMAD
Middle Name:
Last Name:IMRAN
Suffix:
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:PO BOX 110
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-0110
Mailing Address - Country:US
Mailing Address - Phone:631-775-7850
Mailing Address - Fax:631-775-7850
Practice Address - Street 1:700 PATCHOGUE YAPHANK RD STE 49
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2239
Practice Address - Country:US
Practice Address - Phone:631-775-7850
Practice Address - Fax:631-775-7850
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019908-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY108213800OtherOWCP#
NY206166POtherHIP PROVIDER#
NYQL818OtherEMPIRE BLUECROSS BLUESHIE
NY6604512OtherGHI #
NYQL6821Medicare PIN