Provider Demographics
NPI:1265567077
Name:ELMWOOD ORTHOPEDIC REHAB CENTER, INC.
Entity type:Organization
Organization Name:ELMWOOD ORTHOPEDIC REHAB CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:YATSKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:617-442-3462
Mailing Address - Street 1:193 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907-1460
Mailing Address - Country:US
Mailing Address - Phone:401-459-4000
Mailing Address - Fax:401-459-4005
Practice Address - Street 1:120 DUDLEY ST STE 201
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2431
Practice Address - Country:US
Practice Address - Phone:401-941-1347
Practice Address - Fax:617-445-7874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT01849225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIE061618Medicaid