MEDICARE: AMITY PHYSICAL THERAPY LLC

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	CT008058	CT
2	225100000X	Physical Therapist	CT006646	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20910	OTHER	CT	ORTHONET
2	080006646CT07	OTHER	CT	BCBS

General Provider Information

NPI Number	:	1528191426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMITY PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	1 BRADLEY RD
Second Line	:	SUITE #801
City	:	WOODBRIDGE
State	:	CT
Zip	:	06525-2285
Country	:	US
Telephone Number	:	203-389-4593
Fax Number	:	203-389-4609

Provider Business Practice Location Address
First Line	:	1 BRADLEY RD
Second Line	:	SUITE #801
City	:	WOODBRIDGE
State	:	CT
Zip	:	06525-2285
Country	:	US
Telephone Number	:	203-389-4593
Fax Number	:	203-389-4609

Authorized Official
Title or Position	:	DIRECTOR PHYSICAL THERAPIST
Name	:	MICHAEL F DOW
Credential	:	MSPT
Telephone Number	:	203-389-4593

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	11/02/2017

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