Provider Demographics
NPI:1023177706
Name:WICK, THOMAS KENNEDY (PT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:KENNEDY
Last Name:WICK
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 1:8826 OAK DR
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-7433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8200 SENECA TPKE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-1027
Practice Address - Country:US
Practice Address - Phone:315-738-1671
Practice Address - Fax:315-738-0942
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003064-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400066356Medicare PIN