Basic Information
| Provider Information | |||||||||
| NPI: | 1952627044 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOMER PHYSICAL THERAPY, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HEYER PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 84 CORTLAND ST | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130771517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077492219 | ||||||||
| FaxNumber: | 6077492286 | ||||||||
| Practice Location | |||||||||
| Address1: | 84 CORTLAND ST | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130771517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077492219 | ||||||||
| FaxNumber: | 6077492286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2010 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HEYER | ||||||||
| AuthorizedOfficialFirstName: | EHREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6077492219 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | 08/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 0258401 | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 02565451 | 05 | NY | MEDICAID | 56533A | 01 | NY | UNSPECIFIED | OTHER |