Provider Demographics
NPI:1972614220
Name:GORMLEY, MICHAEL C (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:GORMLEY
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 1:549 4TH ST
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14301-1530
Mailing Address - Country:US
Mailing Address - Phone:716-284-2848
Mailing Address - Fax:716-284-2848
Practice Address - Street 1:549 4TH ST
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14301-1530
Practice Address - Country:US
Practice Address - Phone:716-284-2848
Practice Address - Fax:716-284-2848
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001405225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00010236301OtherUNIVERA
NY000607209001OtherBLUE CROSS BLUE SHIELD
NY00609485Medicaid
NY9308303OtherINDEPENDENT HEALTH
NY072091Medicare ID - Type Unspecified