Provider Demographics
NPI:1619367844
Name:REHABILITATION ASSOCIATE OF LI PHYSICAL MEDICINE PLLC
Entity type:Organization
Organization Name:REHABILITATION ASSOCIATE OF LI PHYSICAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GAUDINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-864-0557
Mailing Address - Street 1:3601 HEMPSTEAD TPKE STE 503
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-1376
Mailing Address - Country:US
Mailing Address - Phone:516-864-0557
Mailing Address - Fax:516-864-0559
Practice Address - Street 1:3601 HEMPSTEAD TPKE STE 503
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-1376
Practice Address - Country:US
Practice Address - Phone:516-864-0557
Practice Address - Fax:516-864-0559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185629-1208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01258511Medicaid
NY00125851Medicaid