Provider Demographics
NPI:1962494740
Name:SULLIVAN, BRENDAN (PT)
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14631
Mailing Address - Street 2:EMPIRE FITNESS & PT, PC
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4631
Mailing Address - Country:US
Mailing Address - Phone:518-690-4406
Mailing Address - Fax:
Practice Address - Street 1:8 CENTURY HILL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2193
Practice Address - Country:US
Practice Address - Phone:518-690-4406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017907225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RB3760Medicare UPIN