Provider Demographics
NPI:1831110683
Name:CARDILLO, CHAD JOSEPH
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:JOSEPH
Last Name:CARDILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 465
Mailing Address - Street 2:
Mailing Address - City:SAUQUOIT
Mailing Address - State:NY
Mailing Address - Zip Code:13456-0465
Mailing Address - Country:US
Mailing Address - Phone:315-736-2080
Mailing Address - Fax:315-736-2162
Practice Address - Street 1:9643 PINNACLE RD
Practice Address - Street 2:
Practice Address - City:SAUQUOIT
Practice Address - State:NY
Practice Address - Zip Code:13456-3041
Practice Address - Country:US
Practice Address - Phone:315-737-7300
Practice Address - Fax:315-737-7301
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022639225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02398878Medicaid
NY02398878Medicaid