Provider Demographics
NPI:1699780338
Name:MARY LOU CORCORAN PT, P.C.
Entity type:Organization
Organization Name:MARY LOU CORCORAN PT, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY LOU
Authorized Official - Middle Name:
Authorized Official - Last Name:CORCORAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:315-637-4747
Mailing Address - Street 1:6711 TOWPATH RD STE 100
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9509
Mailing Address - Country:US
Mailing Address - Phone:315-637-4747
Mailing Address - Fax:315-637-6711
Practice Address - Street 1:6711 TOWPATH RD STE 100
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9509
Practice Address - Country:US
Practice Address - Phone:315-637-4747
Practice Address - Fax:315-637-6711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006344-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAU96Medicaid
NYAA1220Medicare PIN