Basic Information
| Provider Information | |||||||||
| NPI: | 1093928400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3061 STATE ROUTE 28 | ||||||||
| Address2: | |||||||||
| City: | HERKIMER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133501041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157170020 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5094 COMMERCIAL DR | ||||||||
| Address2: | |||||||||
| City: | YORKVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134951106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157688521 | ||||||||
| FaxNumber: | 3157687882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 03/06/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 022174-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.