Basic Information
| Provider Information | |||||||||
| NPI: | 1144656166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEZICK | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | MARSHALL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT, DPT, ATC, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 54 MIDDLESEX TPKE STE 101L | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017301417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812298011 | ||||||||
| FaxNumber: | 7812298374 | ||||||||
| Practice Location | |||||||||
| Address1: | 54 MIDDLESEX TPKE STE 101L | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812298011 | ||||||||
| FaxNumber: | 7812298374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2013 | ||||||||
| LastUpdateDate: | 03/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 20748 | MA | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 225100000X | 20748 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.