Provider Demographics
NPI:1083792196
Name:CUSIMANO, PETER (PT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:CUSIMANO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-476-1792
Practice Address - Street 1:526 OLD LIVERPOOL RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6238
Practice Address - Country:US
Practice Address - Phone:315-457-7005
Practice Address - Fax:315-457-7214
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023140225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP77591Medicare UPIN
NYRA6320Medicare PIN
NYP00425571Medicare PIN