Provider Demographics
NPI:1902451107
Name:ACTIVE LIFE HEALTH OF GARDEN CITY MEDICAL PLLC
Entity Type:Organization
Organization Name:ACTIVE LIFE HEALTH OF GARDEN CITY MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-928-1697
Mailing Address - Street 1:623 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4771
Mailing Address - Country:US
Mailing Address - Phone:516-331-2082
Mailing Address - Fax:516-784-5232
Practice Address - Street 1:623 STEWART AVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4771
Practice Address - Country:US
Practice Address - Phone:516-331-2082
Practice Address - Fax:516-784-5232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-05
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty