Provider Demographics
NPI:1972538585
Name:GLENN SEGAL PHYSICAL THERAPY P.C.
Entity type:Organization
Organization Name:GLENN SEGAL PHYSICAL THERAPY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYISCAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:HARRIS
Authorized Official - Last Name:SEGAL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:631-277-6767
Mailing Address - Street 1:152 ISLIP AVE
Mailing Address - Street 2:STE.15
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-3225
Mailing Address - Country:US
Mailing Address - Phone:631-277-6767
Mailing Address - Fax:631-277-4311
Practice Address - Street 1:152 ISLIP AVE
Practice Address - Street 2:STE.15
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3225
Practice Address - Country:US
Practice Address - Phone:631-277-6767
Practice Address - Fax:631-277-4311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017632-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01891565Medicaid
NY01891565Medicaid
NYQ40891Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER #