Provider Demographics
NPI:1679657639
Name:KACZMAREK, PHILLIP J (DC, PT)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:J
Last Name:KACZMAREK
Suffix:
Gender:M
Credentials:DC, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2448 UNION RD
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14227-2230
Mailing Address - Country:US
Mailing Address - Phone:716-656-0200
Mailing Address - Fax:716-656-0055
Practice Address - Street 1:2448 UNION RD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14227-2230
Practice Address - Country:US
Practice Address - Phone:716-656-0200
Practice Address - Fax:716-656-0055
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010491-1111NR0400X
NY018590-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9311595OtherINDEPENDENT HEALTH, PT
NY00025998702OtherUNIVERA, PT
NY006268201OtherCOMMUNITY BLUE, PT
NY9311595OtherINDEPENDENT HEALTH, PT
NYDD1824Medicare ID - Type UnspecifiedMEDICARE, PHYSICAL THERAP