Provider Demographics
NPI:1629021274
Name:SPORT REHAB PHYSICAL THERAPY PLLC
Entity Type:Organization
Organization Name:SPORT REHAB PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER- PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:TONSOLINE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT, ATC
Authorized Official - Phone:716-683-9310
Mailing Address - Street 1:5102 TRANSIT RD
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-4465
Mailing Address - Country:US
Mailing Address - Phone:716-683-9310
Mailing Address - Fax:716-683-7961
Practice Address - Street 1:5102 TRANSIT RD
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-4465
Practice Address - Country:US
Practice Address - Phone:716-683-9310
Practice Address - Fax:716-683-7961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYS009291225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA0925Medicare ID - Type UnspecifiedGROUP NUMBER