Basic Information
| Provider Information | |||||||||
| NPI: | 1477883999 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PERFORMANCE PHYSICAL THERAPY OF CT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PERFORMANCE PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 35 RIVER RD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | COS COB | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068072759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034220679 | ||||||||
| FaxNumber: | 2034220931 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 POST RD W | ||||||||
| Address2: | |||||||||
| City: | WESTPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068804701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035579165 | ||||||||
| FaxNumber: | 2035579166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2010 | ||||||||
| LastUpdateDate: | 09/21/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILKOWSKI | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2034220679 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.