Provider Demographics
NPI:1861715831
Name:ACTIVE EAST PHYSICAL THERAPY, P.C.
Entity type:Organization
Organization Name:ACTIVE EAST PHYSICAL THERAPY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:P
Authorized Official - Last Name:MOBIUS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:631-377-3488
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11969-0967
Mailing Address - Country:US
Mailing Address - Phone:631-377-3488
Mailing Address - Fax:
Practice Address - Street 1:1370 MAJORS PATH
Practice Address - Street 2:SUITE A
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-2431
Practice Address - Country:US
Practice Address - Phone:631-377-3488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-05
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01639512081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ225310Medicare PIN