Basic Information
| Provider Information | |||||||||
| NPI: | 1134372766 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METRO ATHLETIC MEDICINE&FITNESS PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | METRO SPORTSMED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 263 7TH AVE | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112153689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183698000 | ||||||||
| FaxNumber: | 7186799341 | ||||||||
| Practice Location | |||||||||
| Address1: | 4911 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112193135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184310073 | ||||||||
| FaxNumber: | 7184310099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2008 | ||||||||
| LastUpdateDate: | 09/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | HAYES | ||||||||
| AuthorizedOfficialFirstName: | EUDELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7183698000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | METRO SPORTS MED | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 332BD1200X | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Dialysis Equipment & Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1134372766 | 01 | NY | DME | OTHER |