Provider Demographics
NPI:1619710936
Name:TISBE, MICHAEL GREGORY (DPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GREGORY
Last Name:TISBE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4996 CHESAPEAKE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4411
Mailing Address - Country:US
Mailing Address - Phone:315-466-2685
Mailing Address - Fax:
Practice Address - Street 1:2981 TOWN CENTER RD
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-8120
Practice Address - Country:US
Practice Address - Phone:315-638-9207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014471-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist