Basic Information
| Provider Information | |||||||||
| NPI: | 1528217098 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARTZELL | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 CHESTNUT ST 1402 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003219999 | ||||||||
| FaxNumber: | 2673393761 | ||||||||
| Practice Location | |||||||||
| Address1: | 682 N WEST END BLVD | ||||||||
| Address2: | |||||||||
| City: | QUAKERTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189514100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158921829 | ||||||||
| FaxNumber: | 2155365378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2008 | ||||||||
| LastUpdateDate: | 11/12/2015 | ||||||||
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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 | J10002379 | DE | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT022528 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1528217098 | 01 | CHAMPUS TRICARE | OTHER | 3581672000 | 01 | IBC AMERIHEALTH | OTHER | 1528217098 | 05 | DE | MEDICAID |