Basic Information
| Provider Information | |||||||||
| NPI: | 1245881457 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DYNAMISM PHYSICAL THERAPY, P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 245 WOODFIELD RD | ||||||||
| Address2: | |||||||||
| City: | WEST HEMPSTEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115522528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9089225762 | ||||||||
| FaxNumber: | 5155650929 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112126705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186843319 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2019 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BORJA | ||||||||
| AuthorizedOfficialFirstName: | NINO POMPEYO ROCCO | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9089225762 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT, DPT | ||||||||
| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2081P2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 06050059 | 05 | NY | MEDICAID |