Provider Demographics
NPI:1588727051
Name:CERNIELLO, RICHARD KYLE (PHYSICAL THERAPIST P)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:KYLE
Last Name:CERNIELLO
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702
Mailing Address - Country:US
Mailing Address - Phone:631-661-0788
Mailing Address - Fax:631-669-2190
Practice Address - Street 1:350 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702
Practice Address - Country:US
Practice Address - Phone:631-661-0788
Practice Address - Fax:631-669-2190
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0154031225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQL9421Medicare ID - Type Unspecified