Provider Demographics
NPI:1528199452
Name:ADVANCE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ADVANCE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVIZZIGUO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:315-672-5063
Mailing Address - Street 1:421 SWANSEA AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206
Mailing Address - Country:US
Mailing Address - Phone:315-672-5063
Mailing Address - Fax:315-672-5461
Practice Address - Street 1:4050 MILTON AVE
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031
Practice Address - Country:US
Practice Address - Phone:315-672-5063
Practice Address - Fax:315-672-5461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010694225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
53692BMedicare ID - Type Unspecified