1063695088 NPI number — SUPER PHYSICAL THERAPY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063695088 NPI number — SUPER PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPER PHYSICAL THERAPY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063695088
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5472 FALCON CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BETHLEHEM
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18017-8211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-951-2654
Provider Business Mailing Address Fax Number:
610-837-1693

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5472 FALCON CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BETHLEHEM
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18017-8211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-951-2654
Provider Business Practice Location Address Fax Number:
610-837-1693
Provider Enumeration Date:
12/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SUPER
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
484-951-2654

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  PT009952L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 265408 . This is a "HIGHMARK BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 718809 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 50075511 . This is a "CAPITAL BLUE CROSS" identifier . This identifiers is of the category "OTHER".




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