Basic Information
| Provider Information | |||||||||
| NPI: | 1891797478 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARSTON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | SELKIRK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121581927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187670426 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 747 MADISON AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122083392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184432279 | ||||||||
| FaxNumber: | 5184437246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 09/14/2007 | ||||||||
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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 | 014677 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3439517 | 01 | NY | AETNA | OTHER | 364247 | 01 | NY | MVP | OTHER | 813120 | 01 | NY | MPN | OTHER | 040617000038 | 01 | NY | FIDELIS | OTHER | 6697905 | 01 | NY | GHI | OTHER | 01966921 | 05 | NY | MEDICAID | 10025376 | 01 | NY | CDPHP | OTHER | 227921 | 01 | NY | WELLCARE | OTHER | 000406994010 | 01 | NY | BSNENY | OTHER | Q03G11 | 01 | NY | EMPIRE BC | OTHER |