Provider Demographics
NPI:1023103959
Name:AUDYCKI, MARTIN PAUL (PT)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:PAUL
Last Name:AUDYCKI
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 1:1564 LONG POND RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4119
Mailing Address - Country:US
Mailing Address - Phone:585-227-2580
Mailing Address - Fax:585-227-3077
Practice Address - Street 1:1564 LONG POND RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4119
Practice Address - Country:US
Practice Address - Phone:585-227-2580
Practice Address - Fax:585-227-3077
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10363225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10363OtherPT LICENSE NUMBER
NY11225297OtherCAQH ID NUMBER
NYRA5931Medicare ID - Type UnspecifiedMEDICARE NUMBER
NYDD3760Medicare ID - Type Unspecified