Provider Demographics
NPI:1518930809
Name:HATHAWAY, JEFFREY W (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
Last Name:HATHAWAY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:792 N MAIN ST
Mailing Address - Street 2:STE 100C
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-1644
Mailing Address - Country:US
Mailing Address - Phone:315-458-2552
Mailing Address - Fax:315-458-2575
Practice Address - Street 1:792 N MAIN ST
Practice Address - Street 2:STE 100C
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-1644
Practice Address - Country:US
Practice Address - Phone:315-458-2552
Practice Address - Fax:315-458-2575
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008280225100000X
PAPT017496225100000X
NC10927225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00004725OtherRAILROAD MEDICARE
NY435663OtherMVP HEALTHCARE
NY000013512OtherBCBS CNY
NC068AXOtherBCBS NC
NY918237001OtherHEALTHNOW NY
NCP00404780OtherRAILROAD MEDICARE SRRGA
NCP00404780OtherRAILROAD MEDICARE SRRGA
NYCC2661Medicare PIN