Provider Demographics
NPI:1528165123
Name:GOLD COAST PHYSICAL THERAPY AND PHYSCIAL THERAPY ASST PLLC
Entity type:Organization
Organization Name:GOLD COAST PHYSICAL THERAPY AND PHYSCIAL THERAPY ASST PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:BITRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:631-262-7855
Mailing Address - Street 1:755 NEW YORK AVENUE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743
Mailing Address - Country:US
Mailing Address - Phone:631-351-7676
Mailing Address - Fax:631-351-7667
Practice Address - Street 1:755 NEW YORK AVENUE
Practice Address - Street 2:SUITE 106
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743
Practice Address - Country:US
Practice Address - Phone:631-351-7676
Practice Address - Fax:631-351-7667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017191-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q0WLX1Medicare ID - Type Unspecified