Provider Demographics
NPI:1932535911
Name:ROERIG, MAXINE (PT)
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:ROERIG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3061 STATE ROUTE 28
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-1041
Mailing Address - Country:US
Mailing Address - Phone:315-717-0020
Mailing Address - Fax:315-717-0024
Practice Address - Street 1:3061 STATE ROUTE 28
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-1041
Practice Address - Country:US
Practice Address - Phone:315-717-0020
Practice Address - Fax:315-717-0024
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027792225100000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program