Basic Information
| Provider Information | |||||||||
| NPI: | 1093797797 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESMET | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | RR 1 BOX 140C | ||||||||
| Address2: | |||||||||
| City: | TOWANDA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 188489787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702651111 | ||||||||
| FaxNumber: | 5702657134 | ||||||||
| Practice Location | |||||||||
| Address1: | 1564 ROUTE 507 | ||||||||
| Address2: | SUITE C | ||||||||
| City: | GREENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184264502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706760700 | ||||||||
| FaxNumber: | 5706760766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 03/11/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-011714L | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 812635 | 01 | PA | FIRST PRIORITY | OTHER | 2495044 | 01 | PA | AETNA | OTHER | 171758 | 01 | PA | BLUE SHIELD | OTHER | 0066515000 | 01 | PA | INDEPENDENCE BLUE SHIELD | OTHER | 50017318 | 01 | PA | CAPITAL BLUE CROSS | OTHER |