Provider Demographics
NPI:1922187947
Name:BENOLERAO, TOM (PT)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:BENOLERAO
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 1:2053 W 1820 N
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-4856
Mailing Address - Country:US
Mailing Address - Phone:845-464-6382
Mailing Address - Fax:845-464-6382
Practice Address - Street 1:324 N 1680 E
Practice Address - Street 2:PHYSICAL THERAPY DEPT
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2500
Practice Address - Country:US
Practice Address - Phone:845-464-6382
Practice Address - Fax:845-464-6382
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10586212-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1000043901OtherAFFINITY
NY173774POtherHIP
NYQ13E71OtherEMPIRE BLUE CROSS BLUE SHIELD
NY02566383Medicaid
NY02566383Medicaid
NYQ25771Medicare PIN