Basic Information
| Provider Information | |||||||||
| NPI: | 1265702864 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLIN | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WIECHMAN | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 730 S BROAD ST | ||||||||
| Address2: | |||||||||
| City: | LANSDALE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194465211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142654595 | ||||||||
| FaxNumber: | 6307608306 | ||||||||
| Practice Location | |||||||||
| Address1: | 5255 W 95TH ST | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084242977 | ||||||||
| FaxNumber: | 7084242988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2012 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070018996 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT029109 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P01061943 | 01 | IL | MEDICARE RAILROAD | OTHER |