Basic Information
| Provider Information | |||||||||
| NPI: | 1417407461 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX REHABILITATION AND HEALTH SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 430 INNOVATION DR | ||||||||
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| City: | BLAIRSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157178096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243434060 | ||||||||
| FaxNumber: | 7243434068 | ||||||||
| Practice Location | |||||||||
| Address1: | 10261 STATE ROUTE 85 | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | KITTANNING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 162018165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247837192 | ||||||||
| FaxNumber: | 7247836830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2016 | ||||||||
| LastUpdateDate: | 10/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | GIANNETTA | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7243434060 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT, DPT, MS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1019541330001 | 05 | PA | MEDICAID |