1063695088 NPI number — SUPER PHYSICAL THERAPY, LLC

Table of content: (NPI 1063695088)

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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