Basic Information
Provider Information | |||||||||
NPI: | 1104981331 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DONLY | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2 W 10TH ST | ||||||||
Address2: |   | ||||||||
City: | MARCUS HOOK | ||||||||
State: | PA | ||||||||
PostalCode: | 190614513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6108598850 | ||||||||
FaxNumber: | 6108597876 | ||||||||
Practice Location | |||||||||
Address1: | 1331 E WYOMING AVE | ||||||||
Address2: | SUITE 4120 | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191243808 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2158311170 | ||||||||
FaxNumber: | 2157447394 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2006 | ||||||||
LastUpdateDate: | 11/04/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT013159L | PA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 0188461701 | 01 | PA | AMERICHOICE | OTHER | 0015717000 | 01 | PA | IBC | OTHER | 01884617 | 05 | PA |   | MEDICAID | 1160738 | 01 |   | KEYSTONE MERCY | OTHER | 053903VLZ | 01 | PA | MEDICARE ID | OTHER | DO343174 | 01 | PA | PA BL SHIELD | OTHER | P00692850 | 01 | PA | RAILROAD MEDICARE | OTHER |