Provider Demographics
NPI:1609109453
Name:LEVINE, JEFFREY (PT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:LEVINE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 PATRICIA M GENOVA DR
Mailing Address - Street 2:EASTERN REHABILITATION NETWORK 5TH FLOOR
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-1500
Mailing Address - Country:US
Mailing Address - Phone:860-667-5450
Mailing Address - Fax:860-667-8416
Practice Address - Street 1:499 FARMINGTON AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1943
Practice Address - Country:US
Practice Address - Phone:860-667-5450
Practice Address - Fax:860-667-8416
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004212362Medicaid
CT076536OtherMEDICARE