Basic Information
| Provider Information | |||||||||
| NPI: | 1992882641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 520 PHILADELPHIA ST | ||||||||
| Address2: | |||||||||
| City: | INDIANA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157013902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7244637478 | ||||||||
| FaxNumber: | 7244630931 | ||||||||
| Practice Location | |||||||||
| Address1: | 7447 ADMIRAL PEARY HWY | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | CRESSON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 166301901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148869315 | ||||||||
| FaxNumber: | 8148869316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT015850 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | FI1870317 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 437008 | 01 | PA | HEALTH AMER/HEALTH ASSUR | OTHER | 7758805 | 01 | PA | AETNA | OTHER |