Provider Demographics
NPI:1053393686
Name:BENNINGTON PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:BENNINGTON PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:VIDETTO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:802-447-2101
Mailing Address - Street 1:328 DEWEY ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2225
Mailing Address - Country:US
Mailing Address - Phone:802-447-2101
Mailing Address - Fax:802-447-1902
Practice Address - Street 1:328 DEWEY ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2225
Practice Address - Country:US
Practice Address - Phone:802-447-2101
Practice Address - Fax:802-447-1902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT108183225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTBENN28712OtherVT BCBS
VT66326OtherMOHAWK VALLEY PLAN
VN2131Medicare ID - Type Unspecified
NYBA0867Medicare PIN