Basic Information
| Provider Information | |||||||||
| NPI: | 1609440361 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNCOLA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1377 MOTOR PKWY STE 307 | ||||||||
| Address2: | |||||||||
| City: | ISLANDIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117495258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142654595 | ||||||||
| FaxNumber: | 6317608306 | ||||||||
| Practice Location | |||||||||
| Address1: | 1919 CHESTNUT ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191033456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155641110 | ||||||||
| FaxNumber: | 2152272739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2021 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT029668 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.