Provider Demographics
NPI:1528482312
Name:STAMATIS, PHILLIP
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:STAMATIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HUDSON VIEW DRIVE, APT 30 E
Mailing Address - Street 2:
Mailing Address - City:BEACON
Mailing Address - State:NY
Mailing Address - Zip Code:12508-1329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1910 SOUTH RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-6027
Practice Address - Country:US
Practice Address - Phone:845-454-0120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002464-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer