Basic Information
Provider Information | |||||||||
NPI: | 1487754891 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHOENIX REHABILITATION AND HEALTH SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 430 INNOVATION DRIVE | ||||||||
Address2: |   | ||||||||
City: | BLAIRSVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 157178096 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7243434060 | ||||||||
FaxNumber: | 7243434069 | ||||||||
Practice Location | |||||||||
Address1: | 430 INNOVATION DRIVE | ||||||||
Address2: |   | ||||||||
City: | BLAIRSVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 157178096 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7243434060 | ||||||||
FaxNumber: | 7243434069 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2006 | ||||||||
LastUpdateDate: | 05/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STAMPER | ||||||||
AuthorizedOfficialFirstName: | RACHEL | ||||||||
AuthorizedOfficialMiddleName: | MARIE | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF PAYOR RELATIONS | ||||||||
AuthorizedOfficialTelephone: | 2059997371 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 2043961000 | 01 | PA | INDEPENDENCE BLUE CR. OT | OTHER | 1350836 | 01 | PA | HIGHMARK BLUE SHIELD OT | OTHER |