Healthcare Provider Details

I. General information

NPI: 1104870773
Provider Name (Legal Business Name): MARK A ROTELLA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 WATERMAN AVE
EAST PROVIDENCE RI
02914-1314
US

IV. Provider business mailing address

105 NEWTOWN RD # A SUITE 5
DANBURY CT
06810-4194
US

V. Phone/Fax

Practice location:
  • Phone: 401-434-1773
  • Fax: 401-435-0500
Mailing address:
  • Phone: 203-739-0765
  • Fax: 203-739-0792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number02006
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number007027
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: