Provider Demographics
NPI:1407930829
Name:SOUTH JEFFERSON PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:SOUTH JEFFERSON PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:315-232-2225
Mailing Address - Street 1:70 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ADAMS
Mailing Address - State:NY
Mailing Address - Zip Code:13605-3102
Mailing Address - Country:US
Mailing Address - Phone:315-232-2225
Mailing Address - Fax:315-232-2800
Practice Address - Street 1:70 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ADAMS
Practice Address - State:NY
Practice Address - Zip Code:13605-3102
Practice Address - Country:US
Practice Address - Phone:315-232-2225
Practice Address - Fax:315-232-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA1662Medicare ID - Type Unspecified