Basic Information
Provider Information | |||||||||
NPI: | 1467439737 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ACKISS | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT,DPT, MS,OCS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 771 PILOT HOUSE DR | ||||||||
Address2: | SUITE A | ||||||||
City: | NEWPORT NEWS | ||||||||
State: | VA | ||||||||
PostalCode: | 236061990 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7578732302 | ||||||||
FaxNumber: | 7578732306 | ||||||||
Practice Location | |||||||||
Address1: | 4020 RAINTREE RD | ||||||||
Address2: | SUITE D | ||||||||
City: | CHESAPEAKE | ||||||||
State: | VA | ||||||||
PostalCode: | 233213749 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7574844241 | ||||||||
FaxNumber: | 7574844487 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2005 | ||||||||
LastUpdateDate: | 04/27/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305004384 | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 5039662 | 01 | VA | AETNA | OTHER | P00814677 | 01 | VA | RAILROAD MEDICARE | OTHER | 1467439737 | 05 | VA |   | MEDICAID |