Basic Information
Provider Information
NPI: 1326339599
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SPINOSO
FirstName: JILL
MiddleName: A
NamePrefix:  
NameSuffix:  
Credential: PT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 231 WALTON ST
Address2: SUITE 200
City: SYRACUSE
State: NY
PostalCode: 132021885
CountryCode: US
TelephoneNumber: 3154780380
FaxNumber: 3154780388
Practice Location
Address1: 5719 WIDEWATERS PKWY
Address2:  
City: DE WITT
State: NY
PostalCode: 132141985
CountryCode: US
TelephoneNumber: 3154491301
FaxNumber: 3154492707
Other Information
ProviderEnumerationDate: 04/22/2011
LastUpdateDate: 04/22/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X010788NYY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

ID Information
IDTypeStateIssuerDescription
0205209101NYMEDCAID GROUPOTHER
AA017101NYMEDICARE GROUPOTHER
AA017201NYMEDICARE GROUP IDOTHER


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