Basic Information
| Provider Information | |||||||||
| NPI: | 1558784876 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANCUSO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 FIREMENS MEMORIAL DR | ||||||||
| Address2: | 115 | ||||||||
| City: | POMONA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109703553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007508616 | ||||||||
| FaxNumber: | 8453628474 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 E 56TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100223609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123557827 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2014 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 036741-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.