Provider Demographics
NPI:1174661995
Name:BACCARELLA, COSMO PHILIP (PT)
Entity Type:Individual
Prefix:MR
First Name:COSMO
Middle Name:PHILIP
Last Name:BACCARELLA
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 1:393 MOFFITT BLVD
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751
Mailing Address - Country:US
Mailing Address - Phone:631-581-0006
Mailing Address - Fax:631-581-0990
Practice Address - Street 1:393 MOFFITT BLVD
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751
Practice Address - Country:US
Practice Address - Phone:631-581-0006
Practice Address - Fax:631-581-0990
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0240191225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ16D71Medicare ID - Type Unspecified