Healthcare Provider Details

I. General information

NPI: 1689661092
Provider Name (Legal Business Name): DOROTHEA BURGET SOUTHWICK P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 BEEMAN WAY
CHAMPLAIN NY
12919
US

IV. Provider business mailing address

PO BOX 702
CHAMPLAIN NY
12919
US

V. Phone/Fax

Practice location:
  • Phone: 518-298-1111
  • Fax: 518-298-1111
Mailing address:
  • Phone: 518-298-1111
  • Fax: 518-298-1111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0065281
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000405998001
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerBLUE SHIELD OF NORTHEASTE
# 2
IdentifierQ66832
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerEMPIRE BCBS
# 3
Identifier110409700
Identifier TypeOTHER
Identifier State
Identifier IssuerUS DEPT OF LABOR OWCP
# 4
IdentifierQ66831
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerEMPIRE BLUE CROSS/EMPIRE
# 5
Identifier141733498
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerEMPIRE STATE PLAN GROUP
# 6
IdentifierGRP405998002
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerBLUE SHIELD OF NORTHEASTE
# 7
Identifier650005243
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE
# 8
Identifier819687
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerEMPIRE STATE PLAN
# 9
Identifier141733498
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerEXCELLUS BLUE CROSS BLUE
# 10
IdentifierP01010652
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerEXCELLUS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: