Basic Information
| Provider Information | |||||||||
| NPI: | 1447235726 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCONLOGUE | ||||||||
| FirstName: | JOANNE | ||||||||
| MiddleName: | MARGARET | ||||||||
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| Credential: | MS PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 127 HOSPITAL DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | VALLEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945892500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075528795 | ||||||||
| FaxNumber: | 7075529638 | ||||||||
| Practice Location | |||||||||
| Address1: | 127 HOSPITAL DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | VALLEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945892500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075528795 | ||||||||
| FaxNumber: | 7075529638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT15484 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT 43438 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5491514 | 01 | AETNA | OTHER | P00120492 | 01 | RAILROAD MEDICARE | OTHER | 97897 | 01 | MEDCOST | OTHER | 1035G | 01 | BCBS | OTHER | 805158 | 01 | PARTNERS MEDICARE | OTHER |