Provider Demographics
NPI:1386754695
Name:YELLOWSTONE PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:YELLOWSTONE PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVRIL
Authorized Official - Middle Name:
Authorized Official - Last Name:MALAKOV
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-846-2300
Mailing Address - Street 1:8811 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-2039
Mailing Address - Country:US
Mailing Address - Phone:718-846-2300
Mailing Address - Fax:718-846-2333
Practice Address - Street 1:8811 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-2039
Practice Address - Country:US
Practice Address - Phone:718-846-2300
Practice Address - Fax:718-846-2333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02006875Medicaid
NY03826CMedicare PIN