Healthcare Provider Details

I. General information

NPI: 1942588124
Provider Name (Legal Business Name): MEGAN R OTIS P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2011
Last Update Date: 07/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 CYPRESS ST
ROME NY
13440-2129
US

IV. Provider business mailing address

801 CYPRESS STREET
ROME NY
13440
US

V. Phone/Fax

Practice location:
  • Phone: 315-339-6740
  • Fax: 315-281-0199
Mailing address:
  • Phone: 315-339-6740
  • Fax: 315-281-0199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number029975-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: