Basic Information
| Provider Information | |||||||||
| NPI: | 1750492377 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'CONNELL | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 430 INNOVATION DRIVE | ||||||||
| Address2: | |||||||||
| City: | BLAIRSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157178096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243434060 | ||||||||
| FaxNumber: | 7243434069 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 S LEHIGH AVE | ||||||||
| Address2: | |||||||||
| City: | FRACKVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179312436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708743530 | ||||||||
| FaxNumber: | 5708743283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT018207 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1750492377 | 01 | PA | ORTHONET | OTHER | 1019541330001 | 05 | PA | MEDICAID | 1878706 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 232918467 | 01 | PA | AETNA | OTHER | 50095047 | 01 | PA | CAPITAL BLUE CROSS | OTHER |