Provider Demographics
NPI:1902818776
Name:OLYNCIW, MICHAEL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:OLYNCIW
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 CRESCENT ST
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-2507
Mailing Address - Country:US
Mailing Address - Phone:718-545-0700
Mailing Address - Fax:718-545-3282
Practice Address - Street 1:2717 CRESCENT ST
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-2507
Practice Address - Country:US
Practice Address - Phone:718-545-0700
Practice Address - Fax:718-545-3282
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5968225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01290188Medicaid
NYR27385Medicare PIN