Provider Demographics
NPI:1437191830
Name:SPORTS THERAPY ALBANY PT, PC D/B/A
Entity type:Organization
Organization Name:SPORTS THERAPY ALBANY PT, PC D/B/A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DITECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:F
Authorized Official - Last Name:FASHOUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-489-2449
Mailing Address - Street 1:21 HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-3118
Mailing Address - Country:US
Mailing Address - Phone:518-439-4543
Mailing Address - Fax:
Practice Address - Street 1:4 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3718
Practice Address - Country:US
Practice Address - Phone:518-489-2449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009771-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400014361Medicare PIN