Provider Demographics
NPI:1588719827
Name:PROGRESSIVE PHYSICAL REHABILITATION
Entity type:Organization
Organization Name:PROGRESSIVE PHYSICAL REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VSEVOLOD
Authorized Official - Middle Name:
Authorized Official - Last Name:ELKANOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:732-370-4855
Mailing Address - Street 1:765 NEWMAN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LINCROFT
Mailing Address - State:NJ
Mailing Address - Zip Code:07738-1543
Mailing Address - Country:US
Mailing Address - Phone:732-370-4855
Mailing Address - Fax:732-344-4484
Practice Address - Street 1:765 NEWMAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LINCROFT
Practice Address - State:NJ
Practice Address - Zip Code:07738
Practice Address - Country:US
Practice Address - Phone:732-370-4855
Practice Address - Fax:732-344-4484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01095600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ086554Medicare ID - Type Unspecified