Basic Information
| Provider Information | |||||||||
| NPI: | 1245588946 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX REHABILITATION AND HEALTH SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 430 INNOVATION DRIVE | ||||||||
| Address2: | |||||||||
| City: | BLAIRSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157178096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243434060 | ||||||||
| FaxNumber: | 7243434069 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 OLD GATESBURG ROAD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | STATE COLLEGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142781912 | ||||||||
| FaxNumber: | 8142781921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2012 | ||||||||
| LastUpdateDate: | 05/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | STAMPER | ||||||||
| AuthorizedOfficialFirstName: | RACHEL | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF PAYOR RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2059997371 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | DC005902L | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 02679500 | 01 | CAPITAL BLUE CROSS | OTHER | 1019541330001 | 05 | PA | MEDICAID |