Basic Information
| Provider Information | |||||||||
| NPI: | 1104012640 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACCESS PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3299 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142403299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162844474 | ||||||||
| FaxNumber: | 7162844484 | ||||||||
| Practice Location | |||||||||
| Address1: | 2316 PINE AVE | ||||||||
| Address2: | |||||||||
| City: | NIAGARA FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 143012338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162844474 | ||||||||
| FaxNumber: | 7162844484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2007 | ||||||||
| LastUpdateDate: | 03/25/2010 | ||||||||
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| AuthorizedOfficialLastName: | FROSOLONE | ||||||||
| AuthorizedOfficialFirstName: | ENRICO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7162844474 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 010913-1 | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 017075-1 | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 025797 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000628316001 | 01 | NY | BC/BS | OTHER | 9313114 | 01 | NY | IHA | OTHER | 03138341 | 05 | NY | MEDICAID | 02726447 | 05 | NY | MEDICAID | 00052890002 | 01 | NY | BC/BS | OTHER |