Basic Information
| Provider Information | |||||||||
| NPI: | 1326054750 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICAL THERAPY ASSOCIATES OF NORTHEAST PENNSYLVANIA INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OLD FORGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704574099 | ||||||||
| FaxNumber: | 5704577205 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OLD FORGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704574099 | ||||||||
| FaxNumber: | 5704577205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 11/26/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POVANDA | ||||||||
| AuthorizedOfficialFirstName: | BERNARD | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5704574099 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 539342 | 01 | AETNA | OTHER | 24765 | 01 | GEISINGER HEALTH PLAN | OTHER | 6699675 | 01 | GHD | OTHER | 1677247 | 01 | HIGHMARK | OTHER |