Provider Demographics
NPI:1366600488
Name:PARK SPORTS PHYSICAL THERAPY AND PARK SLOPE OCCUPATIONAL THERAPY, PLLC
Entity type:Organization
Organization Name:PARK SPORTS PHYSICAL THERAPY AND PARK SLOPE OCCUPATIONAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GILZON
Authorized Official - Suffix:
Authorized Official - Credentials:PT, CHT
Authorized Official - Phone:718-230-1180
Mailing Address - Street 1:325 GARFIELD PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-2351
Mailing Address - Country:US
Mailing Address - Phone:718-230-1180
Mailing Address - Fax:
Practice Address - Street 1:325 GARFIELD PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-2351
Practice Address - Country:US
Practice Address - Phone:718-230-1180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011045225100000X
NY013213225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA804120OtherOXFORD ID#
NYQU9581OtherEMPIRE BLUE CROSS BLUE SHEILD