NPIMap

Organization Active NPI

Nicole Derue Physical Therapy P.C.

  • Physical Therapy Clinic/Center
  • Central Square, NY
National Provider Identifier
1053503185
Registry record updated Nov 21, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical Therapy Clinic/CenterTaxonomy code 261QP2000X
License
0590998 Issued in NY
Legal business name
NICOLE DERUE PHYSICAL THERAPY P.C.
Practice address
573 S Main St
Central Square, NY 13036-9785
Phone
(315) 676-3826
Fax
(315) 676-3402
NPI assigned
Aug 13, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 21, 2007

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Nicole Blythe Derue, P.TNPI 1629135371
Title
President
Phone
(315) 676-3826

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapy Clinic/Center 261QP2000X 0590998 NY Primary

Addresses

Primary practice location

573 S Main St
Central Square, NY 13036-9785

Mailing address

573 S Main St
Central Square, NY 13036-9785
Phone (315) 676-3826

Other names 1

  • Fairway Physical Therapy North Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20071012000269 NY Part B Supplier - Clinic/Group Practice 3971699596 Receives reassigned benefits from 2 practitioners
Practice locations: Central Square, NY

National Provider Directory

National Provider Directory

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1186963200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1195603200000",
    "number": "1053503185",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "573 S MAIN ST",
            "city": "CENTRAL SQUARE",
            "state": "NY",
            "postal_code": "130369785",
            "telephone_number": "315-676-3826",
            "fax_number": "315-676-3402"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "573 S MAIN ST",
            "city": "CENTRAL SQUARE",
            "state": "NY",
            "postal_code": "130369785",
            "telephone_number": "315-676-3826",
            "fax_number": "315-676-3402"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NICOLE DERUE PHYSICAL THERAPY P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-08-13",
        "last_updated": "2007-11-21",
        "status": "A",
        "authorized_official_last_name": "DERUE",
        "authorized_official_first_name": "NICOLE",
        "authorized_official_middle_name": "BLYTHE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "315-676-3826",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "P.T"
    },
    "taxonomies": [
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": "NY",
            "license": "0590998",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Fairway Physical Therapy North",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Central Square, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 21, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.