Provider Demographics
NPI:1093831414
Name:FIRST AVEUNUE OCCUPATIONAL MEDICINE,LLC
Entity Type:Organization
Organization Name:FIRST AVEUNUE OCCUPATIONAL MEDICINE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHYSICAL THERAPY
Authorized Official - Prefix:
Authorized Official - First Name:EDWRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ORUCH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:610-265-3200
Mailing Address - Street 1:860 1ST AVE
Mailing Address - Street 2:SUITE870
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-1404
Mailing Address - Country:US
Mailing Address - Phone:610-265-3200
Mailing Address - Fax:610-265-6522
Practice Address - Street 1:860 1ST AVE
Practice Address - Street 2:SUITE870
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-1404
Practice Address - Country:US
Practice Address - Phone:610-265-3200
Practice Address - Fax:610-265-6522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT005823L261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA026644Medicare ID - Type Unspecified