Provider Demographics
NPI:1588872113
Name:NASSAU SPORTS PHYSICAL THERAPY & REHABILITATION PC
Entity type:Organization
Organization Name:NASSAU SPORTS PHYSICAL THERAPY & REHABILITATION PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:GALLAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-747-5050
Mailing Address - Street 1:300 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 191
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4198
Mailing Address - Country:US
Mailing Address - Phone:516-747-5050
Mailing Address - Fax:516-747-5929
Practice Address - Street 1:300 OLD COUNTRY RD
Practice Address - Street 2:SUITE 191
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4198
Practice Address - Country:US
Practice Address - Phone:516-747-5050
Practice Address - Fax:516-747-5929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009165-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWXWTT1Medicare PIN