Basic Information
| Provider Information | |||||||||
| NPI: | 1992932305 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OBURCHAY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077297000 | ||||||||
| FaxNumber: | 6077294554 | ||||||||
| Practice Location | |||||||||
| Address1: | 4401 VESTAL PKWY E | ||||||||
| Address2: | |||||||||
| City: | VESTAL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138503514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077297000 | ||||||||
| FaxNumber: | 6077294554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2009 | ||||||||
| LastUpdateDate: | 04/17/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 031433 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 03111259 | 05 | NY | MEDICAID |