MEDICARE: SPORTS THERAPY ALBANY PT, PC D/B/A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	009771-1	NY

General Provider Information

NPI Number	:	1437191830
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORTS THERAPY ALBANY PT, PC D/B/A

Provider Business Mailing Address
First Line	:	21 HAWTHORNE AVE
Second Line	:
City	:	DELMAR
State	:	NY
Zip	:	12054-3118
Country	:	US
Telephone Number	:	518-439-4543
Fax Number	:

Provider Business Practice Location Address
First Line	:	4 EXECUTIVE PARK DR
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12203-3718
Country	:	US
Telephone Number	:	518-489-2449
Fax Number	:

Authorized Official
Title or Position	:	DITECTOR
Name	:	THOMAS F FASHOUER
Credential	:
Telephone Number	:	518-489-2449

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	06/30/2010

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