Provider Demographics
NPI:1497887756
Name:PORT JEFFERSON PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:PORT JEFFERSON PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:W
Authorized Official - Last Name:WETSELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:631-331-1070
Mailing Address - Street 1:300 HALLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1227
Mailing Address - Country:US
Mailing Address - Phone:631-331-1070
Mailing Address - Fax:631-331-1126
Practice Address - Street 1:300 HALLOCK AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1227
Practice Address - Country:US
Practice Address - Phone:631-331-1070
Practice Address - Fax:631-331-1126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0022662251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ1WSQ1Medicare ID - Type Unspecified