Provider Demographics
NPI:1053503185
Name:NICOLE DERUE PHYSICAL THERAPY P.C.
Entity Type:Organization
Organization Name:NICOLE DERUE PHYSICAL THERAPY P.C.
Other - Org Name:FAIRWAY PHYSICAL THERAPY NORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:BLYTHE
Authorized Official - Last Name:DERUE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:315-676-3826
Mailing Address - Street 1:573 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTRAL SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:13036-9785
Mailing Address - Country:US
Mailing Address - Phone:315-676-3826
Mailing Address - Fax:315-676-3402
Practice Address - Street 1:573 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-9785
Practice Address - Country:US
Practice Address - Phone:315-676-3826
Practice Address - Fax:315-676-3402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0590998261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA1215Medicare PIN