Provider Demographics
NPI:1881605822
Name:MAINOLFI, MICHAEL JOHN (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:MAINOLFI
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 1:5 ALBERT CREE DR
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701
Mailing Address - Country:US
Mailing Address - Phone:802-775-1300
Mailing Address - Fax:802-773-9300
Practice Address - Street 1:5 ALBERT CREE DR
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701
Practice Address - Country:US
Practice Address - Phone:802-775-1300
Practice Address - Fax:802-773-9300
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400002520225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
43430OtherMVP
00028306OtherBLUE CROSS BLUE SHIELD VT
7026628OtherAETNA
VTOVN2146Medicaid
P00646485Medicare PIN
00028306OtherBLUE CROSS BLUE SHIELD VT