1376615724 NPI number — PEAK PHYSICAL THERAPY SOUTH PLLC

Table of content: (NPI 1376615724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376615724 NPI number — PEAK PHYSICAL THERAPY SOUTH PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEAK PHYSICAL THERAPY SOUTH PLLC
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:
Provider Other Organization Name Type Code:
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:
1376615724
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
84 EAST MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTONVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12586
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-496-1616
Provider Business Mailing Address Fax Number:
845-496-1674

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
84 EAST MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTONVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-496-1616
Provider Business Practice Location Address Fax Number:
845-496-1674
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIRECTOR PHYSICAL THERAPIST
Authorized Official Telephone Number:
845-496-1616

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  0133321 , 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)

  • Identifier: Q08K31 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1193077 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10034454 . This is a "CDPHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 42898 . This is a "MVP" identifier . This identifiers is of the category "OTHER".
  • Identifier: K095 . This is a "CDPHP GR#" identifier . This identifiers is of the category "OTHER".
  • Identifier: 44709625 . This is a "HIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1000017827 . This is a "AFFINITY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 20547P . This is a "PRIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5299092 . This is a "AETNA NON HMO" identifier . This identifiers is of the category "OTHER".




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