1558791020 NPI number — ORTHOPEDIC AND SPORTS PHYSICAL THERAPY ASSOC INC

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 1558791020 NPI number — ORTHOPEDIC AND SPORTS PHYSICAL THERAPY ASSOC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOPEDIC AND SPORTS PHYSICAL THERAPY ASSOC INC
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:
1558791020
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 LINCOLN AVE
Provider Second Line Business Mailing Address:
SUITE 209
Provider Business Mailing Address City Name:
N CHARLEROI
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15022-2451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-483-2159
Provider Business Mailing Address Fax Number:
724-489-4758

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3109 UNIVERSITY AVE STE C
Provider Second Line Business Practice Location Address:
SELLARO PLAZA
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26505-3205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-241-4020
Provider Business Practice Location Address Fax Number:
304-241-4029
Provider Enumeration Date:
11/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HENSON
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
724-483-3610

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OC000858L , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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