Provider Demographics
NPI:1558322784
Name:FITNESS SPORTS AND PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:FITNESS SPORTS AND PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WHIELDON
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:716-662-2949
Mailing Address - Street 1:4063 N BUFFALO ST
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2442
Mailing Address - Country:US
Mailing Address - Phone:716-662-2949
Mailing Address - Fax:716-662-3673
Practice Address - Street 1:4063 N BUFFALO ST
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2442
Practice Address - Country:US
Practice Address - Phone:716-662-2949
Practice Address - Fax:716-662-3673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0079921225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006103111OtherBLUE CROSS BLUE SHIELD
NY9352186OtherINDEPENDENT HEALTH
NY00011189901OtherUNIVEX
036747Medicare ID - Type Unspecified
NY006103111OtherBLUE CROSS BLUE SHIELD