Provider Demographics
NPI:1538202742
Name:GANANDA WALWORTH PHYSICAL THERAPY
Entity type:Organization
Organization Name:GANANDA WALWORTH PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:RIGNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-986-1528
Mailing Address - Street 1:PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:MACEDON
Mailing Address - State:NY
Mailing Address - Zip Code:14502-0162
Mailing Address - Country:US
Mailing Address - Phone:315-986-1528
Mailing Address - Fax:
Practice Address - Street 1:1218 MAYBERRY PL
Practice Address - Street 2:
Practice Address - City:MACEDON
Practice Address - State:NY
Practice Address - Zip Code:14502-8773
Practice Address - Country:US
Practice Address - Phone:315-986-1528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023543-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA1525Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER