Provider Demographics
NPI:1053417410
Name:UPSTATE PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:UPSTATE PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:INFANZON
Authorized Official - Suffix:
Authorized Official - Credentials:P T
Authorized Official - Phone:940-483-9020
Mailing Address - Street 1:4401 NORTH I-35
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76207
Mailing Address - Country:US
Mailing Address - Phone:940-483-9020
Mailing Address - Fax:940-483-9021
Practice Address - Street 1:4401 NORTH I-35
Practice Address - Street 2:SUITE 110
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76207
Practice Address - Country:US
Practice Address - Phone:940-483-9020
Practice Address - Fax:940-483-9021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX655410000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4LVOtherBCBS OF TX GROUP NUMBER
TX168705501Medicaid
TX00606XMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER