Provider Demographics
NPI:1225110653
Name:DEBRUIN, PHILIP CARL (MPT)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:CARL
Last Name:DEBRUIN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 BUCKLEY RD
Mailing Address - Street 2:DONALD J. MITCHELL VA CLINIC
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440
Mailing Address - Country:US
Mailing Address - Phone:315-334-7120
Mailing Address - Fax:
Practice Address - Street 1:125 BUCKLEY RD
Practice Address - Street 2:DONALD J. MITCHELL VA CLINIC
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440
Practice Address - Country:US
Practice Address - Phone:315-334-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021618225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist