Provider Demographics
NPI:1255393930
Name:PREMIER PHYSICAL THERAPY OF THE FINGERLAKES, PLLC
Entity type:Organization
Organization Name:PREMIER PHYSICAL THERAPY OF THE FINGERLAKES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:585-394-3920
Mailing Address - Street 1:229 PARRISH STREET
Mailing Address - Street 2:SUITE 220
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424
Mailing Address - Country:US
Mailing Address - Phone:585-394-3920
Mailing Address - Fax:585-394-3997
Practice Address - Street 1:229 PARRISH STREET
Practice Address - Street 2:SUITE 220
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424
Practice Address - Country:US
Practice Address - Phone:585-394-3920
Practice Address - Fax:585-394-3997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2000X
NY014144-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY020114144OtherEXCELLUS BC BS
NY02632479Medicaid
NY0185042370OtherEXCELLUS BLUE CHOICE
NYDC4683OtherMEDICARE RAILROAD
NY601318000OtherOWCP
NY7735556OtherAETNA
NY145851FTOtherPREFERRED CARE
NY145851FTOtherPREFERRED CARE