Provider Demographics
NPI:1154575074
Name:MICHAEL SCOTTODIMASO, PT, PLLC
Entity type:Organization
Organization Name:MICHAEL SCOTTODIMASO, PT, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTTODIMASO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:631-669-0333
Mailing Address - Street 1:51 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-2928
Mailing Address - Country:US
Mailing Address - Phone:631-669-0333
Mailing Address - Fax:631-669-2436
Practice Address - Street 1:51 JOHN ST STE 3
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-2928
Practice Address - Country:US
Practice Address - Phone:631-669-0333
Practice Address - Fax:631-669-2436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01294512081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicare PIN