Provider Demographics
NPI:1174549463
Name:PHYSICAL THERAPY ASSOCIATES OF LAKE SUCCESS, PC
Entity type:Organization
Organization Name:PHYSICAL THERAPY ASSOCIATES OF LAKE SUCCESS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:HITSOUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-353-0256
Mailing Address - Street 1:444 LAKEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1165
Mailing Address - Country:US
Mailing Address - Phone:516-353-0256
Mailing Address - Fax:
Practice Address - Street 1:444 LAKEVILLE RD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1165
Practice Address - Country:US
Practice Address - Phone:516-353-0256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003786208100000X
NY004454208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX I.D.