Basic Information
Provider Information | |||||||||
NPI: | 1154331486 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LIVERPOOL PHYSICAL THERAPY, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1001 W FAYETTE ST | ||||||||
Address2: | STE 400 | ||||||||
City: | SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 132042859 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154721488 | ||||||||
FaxNumber: | 3154728060 | ||||||||
Practice Location | |||||||||
Address1: | 526 OLD LIVERPOOL RD | ||||||||
Address2: | STE 4 | ||||||||
City: | LIVERPOOL | ||||||||
State: | NY | ||||||||
PostalCode: | 130886238 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154577005 | ||||||||
FaxNumber: | 3154577214 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2006 | ||||||||
LastUpdateDate: | 05/06/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CUSIMANO | ||||||||
AuthorizedOfficialFirstName: | PETER | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3154577005 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.