Basic Information
| Provider Information | |||||||||
| NPI: | 1619020112 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEITRICH | ||||||||
| FirstName: | PATRICIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 PHILADELPHIA ST | ||||||||
| Address2: | |||||||||
| City: | INDIANA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157013902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7244637478 | ||||||||
| FaxNumber: | 7244630931 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 MARKET ST | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | BLOOMSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178152600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707841896 | ||||||||
| FaxNumber: | 5707841897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT005500L | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 34765 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 547051 | 01 | PA | HEALTH AMER.ASSUR. | OTHER | 50066058 | 01 | PA | KHPC-CAPITAL | OTHER |