Basic Information
| Provider Information | |||||||||
| NPI: | 1457457871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CALVERT | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | JACKSON | ||||||||
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| Credential: | M.S., P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 430 INNOVATION DRIVE | ||||||||
| Address2: | |||||||||
| City: | BLAIRSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157178096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243434060 | ||||||||
| FaxNumber: | 7243434069 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 VALLEY FORGE RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | PHOENIXVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194602658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109170725 | ||||||||
| FaxNumber: | 6109170573 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 01/13/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT007283L | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0516599000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 234443 | 01 | PA | HEALTH AMER/HEALTH ASSUR | OTHER | JA667629 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |