MEDICARE: JOHN WILLIAM REALE MPT

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	023156	NY

General Provider Information

NPI Number	:	1528844941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN WILLIAM REALE MPT

Provider Business Mailing Address
First Line	:	5813 INNSBRUCK RD
Second Line	:
City	:	EAST SYRACUSE
State	:	NY
Zip	:	13057-3056
Country	:	US
Telephone Number	:	315-420-4428
Fax Number	:

Provider Business Practice Location Address
First Line	:	5813 INNSBRUCK RD
Second Line	:
City	:	EAST SYRACUSE
State	:	NY
Zip	:	13057-3056
Country	:	US
Telephone Number	:	315-420-4428
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2023
Last Update Date	:	09/01/2023

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