NPIMap

Organization Active NPI

Port Jefferson Physical Therapy PC

  • Orthopedic Physical Therapist
  • Port Jefferson Station, NY
National Provider Identifier
1497887756
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Orthopedic Physical TherapistTaxonomy code 2251X0800X
License
002266 Issued in NY
Legal business name
PORT JEFFERSON PHYSICAL THERAPY PC
Practice address
300 Hallock Ave
Port Jefferson Station, NY 11776-1227
Phone
(631) 331-1070
Fax
(631) 331-1126
NPI assigned
Mar 12, 2007
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

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

Authorized official

Name
Mr. Roger W Wetsell, PHYSICAL THERAPISTNPI 1316045032
Title
Owner
Phone
(631) 331-1070

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
Orthopedic Physical Therapist 2251X0800X 002266 NY Primary

Addresses

Primary practice location

300 Hallock Ave
Port Jefferson Station, NY 11776-1227

Mailing address

300 Hallock Ave
Port Jefferson Station, NY 11776-1227
Phone (631) 331-1070

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040317001473 NY Part B Supplier - Clinic/Group Practice 8325938962 Receives reassigned benefits from 3 practitioners
Practice locations: Port Jefferson Station, NY

National Provider Directory

National Provider Directory

Locations

156 E Main St
Huntington, NY 11743

300 Hallock Ave
Port Jefferson Station, NY 11776
Phone (631) 331-1070

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1173657600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1497887756",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 HALLOCK AVE",
            "city": "PORT JEFFERSON STATION",
            "state": "NY",
            "postal_code": "117761227",
            "telephone_number": "631-331-1070",
            "fax_number": "631-331-1126"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "300 HALLOCK AVE",
            "city": "PORT JEFFERSON STATION",
            "state": "NY",
            "postal_code": "117761227",
            "telephone_number": "631-331-1070",
            "fax_number": "631-331-1126"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PORT JEFFERSON PHYSICAL THERAPY PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-12",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "WETSELL",
        "authorized_official_first_name": "ROGER",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "631-331-1070",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "PHYSICAL THERAPIST"
    },
    "taxonomies": [
        {
            "code": "2251X0800X",
            "taxonomy_group": "",
            "desc": "Physical Therapist, Orthopedic",
            "state": "NY",
            "license": "002266",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Port Jefferson Station, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; 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.