Basic Information
| Provider Information | |||||||||
| NPI: | 1518393099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIELLER | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | PT | ||||||||
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| 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: | 6970 FOX HUNT LN | ||||||||
| Address2: | |||||||||
| City: | GLOUCESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230615394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046948111 | ||||||||
| FaxNumber: | 8046945574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2013 | ||||||||
| LastUpdateDate: | 01/31/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 003444 | CT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 036867 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2305003777 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | C05954 | 01 | VA | MEDICARE GROUP PTAN | OTHER | 1518393099 | 01 | VA | MEDICAID QMB ONLY | OTHER |