Provider Demographics
NPI:1841490836
Name:WOODSIDE MEDICAL REBABILITATION, PC
Entity type:Organization
Organization Name:WOODSIDE MEDICAL REBABILITATION, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MISS
Authorized Official - First Name:EUNYUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:KWON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-986-5841
Mailing Address - Street 1:PO BOX 540975
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-0975
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14370 SANFORD AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2044
Practice Address - Country:US
Practice Address - Phone:718-986-5841
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04670Medicare PIN
NYC30685Medicare UPIN