Provider Demographics
NPI:1649874405
Name:SHISHKIN PHYSICAL THERAPY REHAB PC
Entity type:Organization
Organization Name:SHISHKIN PHYSICAL THERAPY REHAB PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHISHKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:347-320-0155
Mailing Address - Street 1:7945 GRAND AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4129
Mailing Address - Country:US
Mailing Address - Phone:347-320-0155
Mailing Address - Fax:
Practice Address - Street 1:107 E BROADWAY FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7037
Practice Address - Country:US
Practice Address - Phone:212-233-0889
Practice Address - Fax:212-233-0898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04599340Medicaid