Provider Demographics
NPI:1699918532
Name:NORTHEAST PHYSICAL MEDICINE & REHABILITATION OF BREWSTER PC
Entity type:Organization
Organization Name:NORTHEAST PHYSICAL MEDICINE & REHABILITATION OF BREWSTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:KOFFLER
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:845-279-1135
Mailing Address - Street 1:1 PADANARAM RD
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811-4836
Mailing Address - Country:US
Mailing Address - Phone:845-279-1135
Mailing Address - Fax:845-279-1440
Practice Address - Street 1:1620 ROUTE 22
Practice Address - Street 2:TOWNE SHOPPING CENTER
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-4051
Practice Address - Country:US
Practice Address - Phone:845-279-1135
Practice Address - Fax:845-279-1440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-08
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100019232Medicare PIN