Provider Demographics
NPI:1740222959
Name:PROCACCINI, MICHAEL VINCENT (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:VINCENT
Last Name:PROCACCINI
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 1:55 HOPEWELL DR
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2340
Mailing Address - Country:US
Mailing Address - Phone:631-258-9538
Mailing Address - Fax:
Practice Address - Street 1:55 HOPEWELL DR
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2340
Practice Address - Country:US
Practice Address - Phone:631-258-9538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2008-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020541-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ12B71Medicare PIN