Provider Demographics
NPI:1790969855
Name:SCOTT FISHER
Entity Type:Organization
Organization Name:SCOTT FISHER
Other - Org Name:AKTIVE ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:CF, PTA
Authorized Official - Phone:607-433-0829
Mailing Address - Street 1:PO BOX 292
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:NY
Mailing Address - Zip Code:13838-0292
Mailing Address - Country:US
Mailing Address - Phone:607-433-0829
Mailing Address - Fax:607-433-0829
Practice Address - Street 1:231 CO. HWY 1
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:13733
Practice Address - Country:US
Practice Address - Phone:607-433-0829
Practice Address - Fax:607-433-0829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC16086332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00256-1OtherPHYSICAL THERAPY LICENSE
NY01901037Medicaid
NY00256-1OtherPHYSICAL THERAPY LICENSE