Provider Demographics
NPI:1073737565
Name:RADISIC, BORIS (PT)
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:RADISIC
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 MEADOWLARK RD
Mailing Address - Street 2:
Mailing Address - City:AUDUBON
Mailing Address - State:PA
Mailing Address - Zip Code:19403-1913
Mailing Address - Country:US
Mailing Address - Phone:610-666-7695
Mailing Address - Fax:
Practice Address - Street 1:830 W CYPRESS ST
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-2218
Practice Address - Country:US
Practice Address - Phone:610-444-6242
Practice Address - Fax:610-444-1391
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT004064L282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital