Healthcare Provider Details

I. General information

NPI: 1912736190
Provider Name (Legal Business Name): JASON INTERMESOLI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 W MAIN ST
PATCHOGUE NY
11772-3008
US

IV. Provider business mailing address

322 W MAIN ST
PATCHOGUE NY
11772-3008
US

V. Phone/Fax

Practice location:
  • Phone: 631-228-4977
  • Fax:
Mailing address:
  • Phone: 631-228-4977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number054022
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number054022
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: