Basic Information
| Provider Information | |||||||||
| NPI: | 1588661235 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORTHOPEDIC AND SPORTS PHYSICAL THERAPY SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EXCEL PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1311 MAMARONECK AVE STE 140 | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106055224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142944050 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 420 BAINBRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191471568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156291270 | ||||||||
| FaxNumber: | 2156291293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | RUCKER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9142944050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2020801 | 01 | NJ | HGHMARK BLUE SHIELD | OTHER | 966448 | 01 | PA | BCBS PPO GROUP # | OTHER | 0099493 | 01 | PA | AETNA HMO GROUP # | OTHER | 4566762 | 01 | PA | AETNA PPO GROUP # | OTHER | A2590262 | 01 | PA | OXFORD GROUP # | OTHER | 0444631000 | 01 | PA | KEYSTONE GROUP # | OTHER | 118100606 | 01 | US DEPT. OF LABOR GRP # | OTHER |