Healthcare Provider Details

I. General information

NPI: 1063735678
Provider Name (Legal Business Name): PRIMARY PHYSICAL THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

358 MADISON ST
WATERVILLE NY
13480-1116
US

IV. Provider business mailing address

5496 E TAFT RD STE 2
NORTH SYRACUSE NY
13212-3784
US

V. Phone/Fax

Practice location:
  • Phone: 315-841-3222
  • Fax: 315-841-4023
Mailing address:
  • Phone: 315-451-6541
  • Fax: 315-451-7059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY W HATHAWAY
Title or Position: OWNER/PT
Credential: PT
Phone: 315-451-6541