Provider Demographics
NPI:1700170545
Name:FITNESS FORUM PHYSICAL AND OCCUPATIONAL THERAPY, PLLC
Entity Type:Organization
Organization Name:FITNESS FORUM PHYSICAL AND OCCUPATIONAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:LINKIEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:315-478-0380
Mailing Address - Street 1:231 WALTON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-1885
Mailing Address - Country:US
Mailing Address - Phone:315-478-0380
Mailing Address - Fax:315-478-0388
Practice Address - Street 1:5719 WIDEWATERS PKWY
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:NY
Practice Address - Zip Code:13214-1985
Practice Address - Country:US
Practice Address - Phone:315-478-0380
Practice Address - Fax:315-478-0388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-08
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011796-1225100000X
NY007223-1225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0683OtherMEDICARE GROUP