Provider Demographics
NPI:1912075763
Name:PHYSICAL THERAPY ASSOCIATES OF SMITHTOWN PC
Entity type:Organization
Organization Name:PHYSICAL THERAPY ASSOCIATES OF SMITHTOWN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:A
Authorized Official - Last Name:BANGER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:631-265-8084
Mailing Address - Street 1:100 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3519
Mailing Address - Country:US
Mailing Address - Phone:631-265-8084
Mailing Address - Fax:631-265-8085
Practice Address - Street 1:100 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3502
Practice Address - Country:US
Practice Address - Phone:631-265-8084
Practice Address - Fax:631-265-8085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQKW071Medicare PIN