Provider Demographics
NPI:1891989661
Name:CREEKSIDE PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:CREEKSIDE PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:716-532-8129
Mailing Address - Street 1:14318 ROUTE 62
Mailing Address - Street 2:
Mailing Address - City:COLLINS
Mailing Address - State:NY
Mailing Address - Zip Code:14034-9788
Mailing Address - Country:US
Mailing Address - Phone:716-532-8129
Mailing Address - Fax:716-532-9201
Practice Address - Street 1:14318 ROUTE 62
Practice Address - Street 2:
Practice Address - City:COLLINS
Practice Address - State:NY
Practice Address - Zip Code:14034-9788
Practice Address - Country:US
Practice Address - Phone:716-532-8129
Practice Address - Fax:716-532-9201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008212261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00010244901OtherUNIVERA
NY9308583OtherINDEPENDENT HEALTH
NY822231OtherEMPIRE
NY000623245003OtherBLUE CROSS/BLUE SHIELD OF
NYAA0301Medicare PIN
NY00010244901OtherUNIVERA