Provider Demographics
NPI:1508876293
Name:ADVANTAGE PHYSICAL THERAPY AT BROOKVIEW
Entity Type:Organization
Organization Name:ADVANTAGE PHYSICAL THERAPY AT BROOKVIEW
Other - Org Name:ADVANTAGE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:FORNABAIO
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT CSCS
Authorized Official - Phone:518-477-6179
Mailing Address - Street 1:568 COLUMBIA TPKE
Mailing Address - Street 2:STE 2
Mailing Address - City:EAST GREENBUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12061
Mailing Address - Country:US
Mailing Address - Phone:518-477-6179
Mailing Address - Fax:518-477-6209
Practice Address - Street 1:568 COLUMBIA TPKE
Practice Address - Street 2:STE 2
Practice Address - City:EAST GREENBUSH
Practice Address - State:NY
Practice Address - Zip Code:12061
Practice Address - Country:US
Practice Address - Phone:518-477-6179
Practice Address - Fax:518-477-6209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA1149Medicare ID - Type Unspecified