Provider Demographics
NPI:1184686636
Name:MARINO, VINCENT JR (PT)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:MARINO
Suffix:JR
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 1:231 WALTON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-1230
Mailing Address - Country:US
Mailing Address - Phone:315-478-0380
Mailing Address - Fax:315-478-0388
Practice Address - Street 1:5719 WIDEWATERS PKWY
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:NY
Practice Address - Zip Code:13214-1880
Practice Address - Country:US
Practice Address - Phone:315-449-1301
Practice Address - Fax:315-449-2707
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015543225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS73351Medicare UPIN
NYBB3915Medicare PIN
NYBB3914Medicare PIN