Basic Information
| Provider Information | |||||||||
| NPI: | 1386977494 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROSE | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | MARCUS HOOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190614513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108598850 | ||||||||
| FaxNumber: | 6108597876 | ||||||||
| Practice Location | |||||||||
| Address1: | 4948 PENNELL RD | ||||||||
| Address2: | |||||||||
| City: | ASTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190141867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104948730 | ||||||||
| FaxNumber: | 6104949671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2009 | ||||||||
| LastUpdateDate: | 06/09/2011 | ||||||||
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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 | PT020163 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3739539000 | 01 | PA | IBC | OTHER | 2135021 | 01 | PA | PENNSYLVANIA BLUE SHIELD | OTHER | 30070454 | 01 | PA | KEYSTONE MERCY | OTHER | 102373669-0001 | 05 | PA | MEDICAID | 1386977494 | 01 | PA | BRAVO | OTHER |