Healthcare Provider Details

I. General information

NPI: 1144329657
Provider Name (Legal Business Name): THOMAS JOSEPH CARROLL JR. MPT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11831 STATE ROUTE 9W
W COXSACKIE NY
12192-3605
US

IV. Provider business mailing address

11831 RT 9W
WEST COXSACKIE NY
12192-3605
US

V. Phone/Fax

Practice location:
  • Phone: 518-731-1157
  • Fax: 518-731-1158
Mailing address:
  • Phone: 518-731-9186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number023390
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: