Provider Demographics
NPI:1912010638
Name:MARINO, MICHAEL A (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:MARINO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4079 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5633
Mailing Address - Country:US
Mailing Address - Phone:718-984-8400
Mailing Address - Fax:718-984-8419
Practice Address - Street 1:4079 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-5633
Practice Address - Country:US
Practice Address - Phone:718-984-8400
Practice Address - Fax:718-984-8419
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7507225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0098027OtherGHI PROVIDER NUMBER
NYP468625OtherOXFORD PROVIDER NUMBER
NY0098027OtherGHI PROVIDER NUMBER
NYQ53102Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER