Provider Demographics
NPI:1356359012
Name:PREMIER PHYSICAL THERAPY AND WELLNESS PC
Entity type:Organization
Organization Name:PREMIER PHYSICAL THERAPY AND WELLNESS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARYANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-861-2630
Mailing Address - Street 1:1536 3RD AVE
Mailing Address - Street 2:5TH FL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-2167
Mailing Address - Country:US
Mailing Address - Phone:212-861-2630
Mailing Address - Fax:212-861-2685
Practice Address - Street 1:346 MAIN AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-1510
Practice Address - Country:US
Practice Address - Phone:203-847-4400
Practice Address - Fax:203-847-4442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q1WCT1Medicare PIN