Provider Demographics
NPI:1114331212
Name:JELKAM PHYSICAL THERAPY
Entity Type:Organization
Organization Name:JELKAM PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:FARDALE
Authorized Official - Last Name:WIMBERLY
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:607-349-8534
Mailing Address - Street 1:24 OAKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-2125
Mailing Address - Country:US
Mailing Address - Phone:607-349-8534
Mailing Address - Fax:
Practice Address - Street 1:24 OAKRIDGE DR
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-2125
Practice Address - Country:US
Practice Address - Phone:607-349-8534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-17
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0218591261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100125564Medicare PIN