Provider Demographics
NPI:1376615724
Name:PEAK PHYSICAL THERAPY SOUTH PLLC
Entity Type:Organization
Organization Name:PEAK PHYSICAL THERAPY SOUTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:MS PT
Authorized Official - Phone:845-496-1616
Mailing Address - Street 1:84 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WASHINGTONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12586
Mailing Address - Country:US
Mailing Address - Phone:845-496-1616
Mailing Address - Fax:845-496-1674
Practice Address - Street 1:84 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WASHINGTONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12586
Practice Address - Country:US
Practice Address - Phone:845-496-1616
Practice Address - Fax:845-496-1674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0133321225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q08K31OtherBCBS
1193077OtherAETNA HMO
10034454OtherCDPHP
42898OtherMVP
K095OtherCDPHP GR#
44709625OtherHIP
1000017827OtherAFFINITY
20547POtherPRIS
5299092OtherAETNA NON HMO
Q08K31OtherBCBS