1255393930 NPI number — PREMIER PHYSICAL THERAPY OF THE FINGERLAKES, PLLC

Table of content: (NPI 1255393930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255393930 NPI number — PREMIER PHYSICAL THERAPY OF THE FINGERLAKES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER PHYSICAL THERAPY OF THE FINGERLAKES, 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:
1255393930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
229 PARRISH STREET
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
CANANDAIGUA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-394-3920
Provider Business Mailing Address Fax Number:
585-394-3997

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
229 PARRISH STREET
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
CANANDAIGUA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-394-3920
Provider Business Practice Location Address Fax Number:
585-394-3997
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARLSON
Authorized Official First Name:
MITCHELL
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
585-394-3920

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  014144-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 020114144 . This is a "EXCELLUS BC BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02632479 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0185042370 . This is a "EXCELLUS BLUE CHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: DC4683 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 601318000 . This is a "OWCP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7735556 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 145851FT . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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