Provider Demographics
NPI:1407042484
Name:THOMAS NICOLLA
Entity Type:Organization
Organization Name:THOMAS NICOLLA
Other - Org Name:NICOLLA PHYSICAL THERAPY OF EAST GREENBUSH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-786-1667
Mailing Address - Street 1:749 COLUMBIA TPKE
Mailing Address - Street 2:
Mailing Address - City:EAST GREENBUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12061-2612
Mailing Address - Country:US
Mailing Address - Phone:518-479-2046
Mailing Address - Fax:518-477-5410
Practice Address - Street 1:749 COLUMBIA TPKE
Practice Address - Street 2:
Practice Address - City:EAST GREENBUSH
Practice Address - State:NY
Practice Address - Zip Code:12061-2612
Practice Address - Country:US
Practice Address - Phone:518-479-2046
Practice Address - Fax:518-477-5410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2009-01-29
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
NY000413955002OtherBSNENY
NY53641BMedicare PIN