Basic Information
Provider Information | |||||||||
NPI: | 1922091719 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ACADEMY PHYSICAL THERAPY, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4567 CROSSROADS PARK DR | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | LIVERPOOL | ||||||||
State: | NY | ||||||||
PostalCode: | 130883589 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3152952100 | ||||||||
FaxNumber: | 3152952126 | ||||||||
Practice Location | |||||||||
Address1: | 6700 KIRKVILLE RD | ||||||||
Address2: | SUITE 202 1/2 | ||||||||
City: | EAST SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 130579305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157011515 | ||||||||
FaxNumber: | 3154491118 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/26/2005 | ||||||||
LastUpdateDate: | 09/13/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GIARDINA | ||||||||
AuthorizedOfficialFirstName: | VINCE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 3157011515 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | P.T. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 020280 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.