Basic Information
| Provider Information | |||||||||
| NPI: | 1881116358 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX REHABILITATION AND HEALTH SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 430 INNOVATION DR | ||||||||
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| City: | BLAIRSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157178096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243434069 | ||||||||
| FaxNumber: | 7243434068 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 W MARKET ST STE 10 | ||||||||
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| City: | ORWIGSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179611011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5709682131 | ||||||||
| FaxNumber: | 5709684027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2017 | ||||||||
| LastUpdateDate: | 07/17/2017 | ||||||||
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| AuthorizedOfficialLastName: | MARCOALDI | ||||||||
| AuthorizedOfficialFirstName: | TRISH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACTING/CRED. SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7243434060 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHOENIX REHABILITATION AND HEALTH SERVICES, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1019541330001 | 05 | PA | MEDICAID |