1518911361 NPI number — JOHN M. CORCORAN PT

Table of content: MS. ELLEN JACOBS OT (NPI 1255458717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518911361 NPI number — JOHN M. CORCORAN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORCORAN
Provider First Name:
JOHN
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1518911361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8 FARAGUT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TONAWANDA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-799-2398
Provider Business Mailing Address Fax Number:
716-626-9193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
INTEGRATIVE PHYSICAL THERAPY OF WNY, PLLC
Provider Second Line Business Practice Location Address:
337 CLEVELAND DR, SUITE 1
Provider Business Practice Location Address City Name:
CHEEKTOWAGA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14215-6800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-800-7725
Provider Business Practice Location Address Fax Number:
716-626-9193
Provider Enumeration Date:
05/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  025007 , 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: 02422420 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".