Provider Demographics
NPI:1093797797
Name:DESMET, EDWARD C JR (MSPT)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:DESMET
Suffix:JR
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 140C
Mailing Address - Street 2:
Mailing Address - City:TOWANDA
Mailing Address - State:PA
Mailing Address - Zip Code:18848-9787
Mailing Address - Country:US
Mailing Address - Phone:570-265-1111
Mailing Address - Fax:570-265-7134
Practice Address - Street 1:1564 ROUTE 507
Practice Address - Street 2:SUITE C
Practice Address - City:GREENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18426-4502
Practice Address - Country:US
Practice Address - Phone:570-676-0700
Practice Address - Fax:570-676-0766
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT-011714L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA812635OtherFIRST PRIORITY
PA2495044OtherAETNA
PA171758OtherBLUE SHIELD
PA0066515000OtherINDEPENDENCE BLUE SHIELD
PA50017318OtherCAPITAL BLUE CROSS