Provider Demographics
NPI:1568899300
Name:FITNESS FORUM PT
Entity Type:Organization
Organization Name:FITNESS FORUM PT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPR
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHOPIRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-469-5990
Mailing Address - Street 1:4994 W SENECA TPKE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215-2279
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4994 W SENECA TPKE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2279
Practice Address - Country:US
Practice Address - Phone:315-469-5990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-10
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization