Provider Demographics
NPI:1528138476
Name:RICHARD BODIAN PT
Entity type:Organization
Organization Name:RICHARD BODIAN PT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DIRECTOR OF REHABILATION
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:BODIAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-451-1480
Mailing Address - Street 1:1655 RICHMOND AVENUE
Mailing Address - Street 2:SUITE B102
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314
Mailing Address - Country:US
Mailing Address - Phone:718-370-3500
Mailing Address - Fax:718-370-9724
Practice Address - Street 1:2133 RALPH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-5405
Practice Address - Country:US
Practice Address - Phone:718-451-1400
Practice Address - Fax:718-451-2797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0094691225X00000X
NY0138081261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ3W1M1Medicare ID - Type Unspecified