MEDICARE: WIRTH PHYSICAL THERAPY PC

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1851958490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WIRTH PHYSICAL THERAPY PC

Provider Business Mailing Address
First Line	:	650 HAWKINS AVE STE 4
Second Line	:
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-2366
Country	:	US
Telephone Number	:	631-981-7422
Fax Number	:	631-981-2490

Provider Business Practice Location Address
First Line	:	650 HAWKINS AVE STE 4
Second Line	:
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-2366
Country	:	US
Telephone Number	:	631-981-7422
Fax Number	:	631-981-2490

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL WIRTH
Credential	:
Telephone Number	:	631-981-7422

Provider Enumeration Date	:	05/20/2019
Last Update Date	:	05/20/2019

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