Basic Information
Provider Information | |||||||||
NPI: | 1083647515 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KONLIAN,O'NEILL & ASSOCIATES, P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AQUACARE PHYSICAL THERAPY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 106 MILFORD ST STE 601 | ||||||||
Address2: |   | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 218046938 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105487600 | ||||||||
FaxNumber: | 4105482651 | ||||||||
Practice Location | |||||||||
Address1: | 106 MILFORD ST STE 601 | ||||||||
Address2: |   | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 218046938 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105487600 | ||||||||
FaxNumber: | 4105482651 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2006 | ||||||||
LastUpdateDate: | 11/12/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BALDWIN | ||||||||
AuthorizedOfficialFirstName: | JANICE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | REGIONAL MANAGER OFFICE ADMIN | ||||||||
AuthorizedOfficialTelephone: | 4105487600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225400000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 067112600 | 05 | MD |   | MEDICAID |