Provider Demographics
NPI:1992137335
Name:SHIELD PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:SHIELD PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JAECHOL
Authorized Official - Middle Name:
Authorized Official - Last Name:AHN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:646-600-3291
Mailing Address - Street 1:8523 BROADWAY
Mailing Address - Street 2:UNIT D
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-5866
Mailing Address - Country:US
Mailing Address - Phone:718-873-2303
Mailing Address - Fax:347-438-1272
Practice Address - Street 1:8523 BROADWAY
Practice Address - Street 2:UNIT D
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5866
Practice Address - Country:US
Practice Address - Phone:718-873-2303
Practice Address - Fax:347-438-1272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031899273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit