Provider Demographics
NPI:1164745774
Name:PRIMARY PHYSICAL THERAPY PLLC
Entity Type:Organization
Organization Name:PRIMARY PHYSICAL THERAPY PLLC
Other - Org Name:PROACTIVE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:HATHAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:315-451-6541
Mailing Address - Street 1:5496 E TAFT RD
Mailing Address - Street 2:STE 2
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-3784
Mailing Address - Country:US
Mailing Address - Phone:315-451-6541
Mailing Address - Fax:315-451-7059
Practice Address - Street 1:792 N MAIN ST
Practice Address - Street 2:STE 100C
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-1644
Practice Address - Country:US
Practice Address - Phone:315-458-2552
Practice Address - Fax:315-458-2575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5464900003Medicare NSC