NPIMap

Organization Active NPI

Pro Form Physical Therapy PC

  • Specialist
  • Bronx, NY
National Provider Identifier
1740621697
Registry record updated Mar 1, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
025663 Issued in NY
Legal business name
PRO FORM PHYSICAL THERAPY PC
Practice address
1973 University Ave
Bronx, NY 10453-4404
Phone
(718) 618-0052
Fax
(718) 534-4135
NPI assigned
Jul 8, 2013
Last updated
Mar 1, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 1, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Sam Hanna, PTNPI 1316971229
Title
Owner/Physical Therapist
Phone
(917) 545-9249

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 174400000X 025663 NY Primary
SpecialistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 174400000X 021421 NY

Addresses

Primary practice location

1973 University Ave
Bronx, NY 10453-4404

Mailing address

95-22 63Rd Road
Suite 412
Rego Park, NY 11374-1142
Phone (718) 618-0052

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20131017000030 NY Part B Supplier - Clinic/Group Practice 0648404137 Receives reassigned benefits from 2 practitioners
Practice locations: Bronx, NY; New York, NY

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1373241600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1456790400000",
    "number": "1740621697",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "95-22 63RD ROAD",
            "address_2": "SUITE 412",
            "city": "REGO PARK",
            "state": "NY",
            "postal_code": "113741142",
            "telephone_number": "718-618-0052",
            "fax_number": "718-534-4135"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1973 UNIVERSITY AVE",
            "city": "BRONX",
            "state": "NY",
            "postal_code": "104534404",
            "telephone_number": "718-618-0052",
            "fax_number": "718-534-4135"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRO FORM PHYSICAL THERAPY PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-07-08",
        "last_updated": "2016-03-01",
        "status": "A",
        "authorized_official_last_name": "HANNA",
        "authorized_official_first_name": "SAM",
        "authorized_official_title_or_position": "OWNER/PHYSICAL THERAPIST",
        "authorized_official_telephone_number": "917-545-9249",
        "authorized_official_credential": "PT"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "NY",
            "license": "025663",
            "primary": true
        },
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "NY",
            "license": "021421",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bronx, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 1, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.