Provider Demographics
NPI:1760772701
Name:ADIRONDACK MANUAL PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:ADIRONDACK MANUAL PHYSICAL THERAPY, PLLC
Other - Org Name:AMPT
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:518-255-5049
Mailing Address - Street 1:221 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12803-5118
Mailing Address - Country:US
Mailing Address - Phone:518-225-5049
Mailing Address - Fax:
Practice Address - Street 1:578 AVIATION RD STE 30
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1814
Practice Address - Country:US
Practice Address - Phone:518-538-8778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027046-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02739691Medicaid
NYG8867029Medicare PIN