Basic Information
| Provider Information | |||||||||
| NPI: | 1578716056 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POTTSTOWN MEDICAL SPECIALISTS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PMSI PAIN MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1610 MEDICAL DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | POTTSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194643292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4849450405 | ||||||||
| FaxNumber: | 4849450379 | ||||||||
| Practice Location | |||||||||
| Address1: | 1610 MEDICAL DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | POTTSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194643292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4849450405 | ||||||||
| FaxNumber: | 4849450379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2008 | ||||||||
| LastUpdateDate: | 03/29/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 10/20/2017 | ||||||||
| NPIReactivationDate: | 03/29/2019 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SBAT | ||||||||
| AuthorizedOfficialFirstName: | KENNEDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER & AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6103274200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | POTTSTOWN MEDICAL SPECIALISTS, INC. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | MD418870 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.