MEDICARE: PHYSICAL THERAPY & ELECTROPHYSIOLOGIC SPECIALIST OF NY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist		NY

General Provider Information

NPI Number	:	1457324832
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICAL THERAPY & ELECTROPHYSIOLOGIC SPECIALIST OF NY PLLC

Provider Business Mailing Address
First Line	:	419 S PETERBORO ST
Second Line	:
City	:	CANASTOTA
State	:	NY
Zip	:	13032-1431
Country	:	US
Telephone Number	:	315-697-6005
Fax Number	:	315-697-6006

Provider Business Practice Location Address
First Line	:	419 S PETERBORO ST
Second Line	:
City	:	CANASTOTA
State	:	NY
Zip	:	13032-1431
Country	:	US
Telephone Number	:	315-697-6005
Fax Number	:	315-697-6006

Authorized Official
Title or Position	:	OWNER OPERATOR
Name	:	MR. JAMES PETER RICCELLI
Credential	:	PT
Telephone Number	:	315-697-6005

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	08/22/2020

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