1245334929 NPI number — MENDON PHYSICAL THERAPY MANAGEMENT, PC

Table of content: (NPI 1245334929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245334929 NPI number — MENDON PHYSICAL THERAPY MANAGEMENT, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MENDON PHYSICAL THERAPY MANAGEMENT, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PITTSFORD MENDON PHYSICAL THERAPY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245334929
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 212
Provider Second Line Business Mailing Address:
110 ASSEMBLY DR
Provider Business Mailing Address City Name:
MENDON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14506-0212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-582-1330
Provider Business Mailing Address Fax Number:
585-582-2537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 ASSEMBLY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENDON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14506-9600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-582-1330
Provider Business Practice Location Address Fax Number:
585-582-2537
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHUMAN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
HAROLD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
585-582-1330

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  011899 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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