=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003262148
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FINGER LAKES PHYSIATRY AND INTEGRATIVE HEALTH CARE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2016
-----------------------------------------------------
Last Update Date | 05/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 821 PRE EMPTION RD STE 200
-----------------------------------------------------
City | GENEVA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14456-2061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-766-0811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 821 PRE EMPTION RD STE 200
-----------------------------------------------------
City | GENEVA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14456-2061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-766-0811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. JAMES MICHAEL INZERILLO
-----------------------------------------------------
Credential | MD, DC
-----------------------------------------------------
Telephone | 631-766-0811
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 7420
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 334820
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 253084
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------