Basic Information
| Provider Information | |||||||||
| NPI: | 1811957541 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARRUTH | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 231 WALTON ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132021230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154780380 | ||||||||
| FaxNumber: | 3154780388 | ||||||||
| Practice Location | |||||||||
| Address1: | 5100 W TAFT RD | ||||||||
| Address2: | SUITE 2K | ||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130883807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154522200 | ||||||||
| FaxNumber: | 3154522204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2006 | ||||||||
| LastUpdateDate: | 10/20/2009 | ||||||||
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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 | 004824 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 02446028 | 05 | NY | MEDICAID |