Basic Information
| Provider Information | |||||||||
| NPI: | 1710923776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILDE | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 518 PELLLIS RD | ||||||||
| Address2: | |||||||||
| City: | GREENSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 156014599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7248321696 | ||||||||
| FaxNumber: | 7248326351 | ||||||||
| Practice Location | |||||||||
| Address1: | 6970 FOX HUNT LN | ||||||||
| Address2: | |||||||||
| City: | GLOUCESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230615394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046948111 | ||||||||
| FaxNumber: | 8046945574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 12/31/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 23052140442 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT003818L | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000424032 | 01 | PA | HIGHMARK | OTHER | 4625101 | 01 | AETNA US HEALTHCARE | OTHER |