Provider Demographics
NPI:1033291802
Name:PETERSON & NELLIS PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:PETERSON & NELLIS PHYSICAL THERAPY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROSIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-476-3176
Mailing Address - Street 1:207 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1137
Mailing Address - Country:US
Mailing Address - Phone:315-476-3176
Mailing Address - Fax:315-476-0171
Practice Address - Street 1:207 PINE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1137
Practice Address - Country:US
Practice Address - Phone:315-476-3176
Practice Address - Fax:315-476-0171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS83109Medicare UPIN
NYBB5524Medicare ID - Type Unspecified
NYR57009Medicare UPIN
NYRA8213Medicare UPIN
NYS83106Medicare UPIN
NYR55750Medicare UPIN
NYS83110Medicare UPIN
NYR57010Medicare UPIN
NY1261560001Medicare NSC