Provider Demographics
NPI:1902928138
Name:PROSPORTS PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:PROSPORTS PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHISHOLM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:631-424-1100
Mailing Address - Street 1:467 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3441
Mailing Address - Country:US
Mailing Address - Phone:631-424-1100
Mailing Address - Fax:631-424-1105
Practice Address - Street 1:467 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3441
Practice Address - Country:US
Practice Address - Phone:631-424-1100
Practice Address - Fax:631-424-1105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7489208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ8W101Medicare ID - Type Unspecified