Susan Sanford, PT LIC ACC – Physical Therapist

Key facts

NPI: 1104905934
Entity type: Individual (NPI type 1)
Primary specialty: Physical Therapist 225100000X
License: 10886 (MA)
Practice address: 238 Edgartown Vineyard Haven Road
Edgartown, MA 02539
Phone: (508) 693-3800
NPI assigned: Nov 3, 2006
Sex: Female
Sole proprietor: No

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Vineyard Complementary Medicine, Inc Physical Therapy Clinic/Center · Edgartown, MA · NPI 1053490896

Medicare reassignment Care Compare group Authorized official MA
Vineyard Complementary Medicine Inc. Acupuncturist · Edgartown, MA · NPI 1598238792

NPD (past) Authorized official ACUPUNCTURIST

Medicare Care Compare profile

Specialty: Physical Therapist in Private Practice
Education: Other, 1994
Medicare assignment: Accepts the Medicare-approved amount as payment in full
Group practices: Vineyard Complementary Medicine Inc (8 clinicians)

Practice addresses (Care Compare)

238 Edgartown Vineyard Haven Rd
Unit 1
Edgartown, MA 02539-6932
Phone (508) 693-3800

Medicare participation

Medicare fee-for-service enrollment: Enrolled in MA

Medicare enrollment records

Enrollment ID	State	Provider type	PAC ID	Details
I20050610000214	MA	Practitioner - Physical Therapist in Private Practice	1759324999	Reassigns benefits to 1 organization

National Provider Directory

Medicare enrollment (NPD): Yes

State licenses

License	State	Type	Specialty
10886	MA	MD	Clinical Psychologist
215639	MA	MD	Acupuncturist
005094	CT	MD	Physical Therapist

Practice roles

Organization	Specialty	Status	New patients
Vineyard Complementary Medicine Inc.	Acupuncturist	Past	Accepting new patients

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Acupuncturist	171100000X	215639	MA
Physical Therapist	225100000X	005094	CT
Physical Therapist	225100000X	10886	MA	Yes

Addresses

Primary practice location

238 Edgartown Vineyard Haven Road
Edgartown, MA 02539

Mailing address

PO Box 951
West Tisbury, MA 02575-0951
Phone (508) 693-3800

Other identifiers

Identifier	Type	State	Issuer
Y68186	Other	MA	BLUE CROSS BLUE SHIELD

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Feb 14, 2023.

{
    "created_epoch": "1162512000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1676332800000",
    "number": "1104905934",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 951",
            "city": "WEST TISBURY",
            "state": "MA",
            "postal_code": "025750951",
            "telephone_number": "508-693-3800",
            "fax_number": "508-693-7473"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "238 EDGARTOWN VINEYARD HAVEN ROAD",
            "city": "EDGARTOWN",
            "state": "MA",
            "postal_code": "02539",
            "telephone_number": "508-693-3800"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SANFORD",
        "first_name": "SUSAN",
        "credential": "PT LIC ACC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-11-03",
        "last_updated": "2023-02-14",
        "certification_date": "2023-02-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "171100000X",
            "taxonomy_group": "",
            "desc": "Acupuncturist",
            "state": "MA",
            "license": "215639",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "CT",
            "license": "005094",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "MA",
            "license": "10886",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "Y68186",
            "state": "MA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Edgartown, MA

All providers in Edgartown, MA · Physical Therapist in Massachusetts

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 14, 2023. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.