Provider Demographics
NPI:1164410221
Name:PENS, CHAD MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:MICHAEL
Last Name:PENS
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 1:37 W GARDEN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-2662
Mailing Address - Country:US
Mailing Address - Phone:315-253-3291
Mailing Address - Fax:315-258-8759
Practice Address - Street 1:37 W GARDEN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-2662
Practice Address - Country:US
Practice Address - Phone:315-253-3291
Practice Address - Fax:315-258-8759
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022423225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02510016Medicaid
NY02510016Medicaid
NYRA6818Medicare ID - Type Unspecified