Provider Demographics
NPI:1780823807
Name:ACTIVE PHYSICAL THERAPY SOLUTIONS PC
Entity Type:Organization
Organization Name:ACTIVE PHYSICAL THERAPY SOLUTIONS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BUCHBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:315-515-3117
Mailing Address - Street 1:4567 CROSSROADS PARK DR
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3589
Mailing Address - Country:US
Mailing Address - Phone:315-295-2100
Mailing Address - Fax:315-295-2125
Practice Address - Street 1:40 W LAKE AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-3724
Practice Address - Country:US
Practice Address - Phone:315-515-3117
Practice Address - Fax:315-515-3121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008418111N00000X
NY028390225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ100000172Medicare PIN
NYJ100000171Medicare PIN