Provider Demographics
NPI:1578646220
Name:SPECTRUM PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:SPECTRUM PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:631-456-5512
Mailing Address - Street 1:100 HOSPITAL RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4821
Mailing Address - Country:US
Mailing Address - Phone:631-456-5512
Mailing Address - Fax:631-456-5514
Practice Address - Street 1:100 HOSPITAL RD
Practice Address - Street 2:SUITE 112
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4821
Practice Address - Country:US
Practice Address - Phone:631-456-5512
Practice Address - Fax:631-456-5514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022096-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
QAWTR1Medicare PIN