Provider Demographics
NPI:1295084382
Name:ROBERT WILUTIS OCCUPATIONAL AND PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:ROBERT WILUTIS OCCUPATIONAL AND PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILUTIS
Authorized Official - Suffix:
Authorized Official - Credentials:OTR, CHT
Authorized Official - Phone:631-331-3608
Mailing Address - Street 1:70 NORTH COUNTRY ROAD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:631-331-3608
Mailing Address - Fax:631-331-2392
Practice Address - Street 1:18 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968
Practice Address - Country:US
Practice Address - Phone:631-331-3608
Practice Address - Fax:631-331-2392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
QRW801Medicare PIN