Provider Demographics
NPI:1770609299
Name:PERFORMANCE PHYSICAL THERAPY OF CT
Entity type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY OF CT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WILKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OCS, SCS
Authorized Official - Phone:203-422-0679
Mailing Address - Street 1:35 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COS COB
Mailing Address - State:CT
Mailing Address - Zip Code:06807-2717
Mailing Address - Country:US
Mailing Address - Phone:203-422-0679
Mailing Address - Fax:203-422-0931
Practice Address - Street 1:35 RIVER RD
Practice Address - Street 2:
Practice Address - City:COS COB
Practice Address - State:CT
Practice Address - Zip Code:06807-2717
Practice Address - Country:US
Practice Address - Phone:203-422-0679
Practice Address - Fax:203-422-0931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03451Medicare PIN
CT6171340001Medicare NSC