Healthcare Provider Details

I. General information

NPI: 1821016577
Provider Name (Legal Business Name): MICHAEL P FALL PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 MOUNTAIN RD
SUFFIELD CT
06078-2091
US

IV. Provider business mailing address

1707 NW SAINT LUCIE WEST BLVD STE 188
PORT SAINT LUCIE FL
34986-2521
US

V. Phone/Fax

Practice location:
  • Phone: 860-668-9589
  • Fax: 860-668-9802
Mailing address:
  • Phone: 772-878-3322
  • Fax: 772-878-5030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number003155
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT33481
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: