Basic Information
| Provider Information | |||||||||
| NPI: | 1861578460 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALYCAM INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PRO REHABILITATION SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1086 ROUTE 315 | ||||||||
| Address2: | |||||||||
| City: | PLAINS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708237761 | ||||||||
| FaxNumber: | 5708228033 | ||||||||
| Practice Location | |||||||||
| Address1: | 87 OXFORD ST | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708253909 | ||||||||
| FaxNumber: | 5708258939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CASSETORI | ||||||||
| AuthorizedOfficialFirstName: | DON | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MGR TREAS | ||||||||
| AuthorizedOfficialTelephone: | 5708237761 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1505622 | 01 | PA | HIGHMARK BLUE CROSS BLUE | OTHER | 5234560 | 01 | PA | AETNA US HEALTHCARE | OTHER | 325504 | 01 | PA | HEALTH AMERICA HEALTH INS | OTHER | 61915 | 01 | PA | GEISINGER | OTHER | 50025209 | 01 | PA | CAPITAL BLUE CROSS BLUE | OTHER |