Provider Demographics
NPI:1275616807
Name:POOLE AVENUE PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:POOLE AVENUE PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:O'LEARY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:723-739-4666
Mailing Address - Street 1:812 POOLE AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:HAZLET
Mailing Address - State:NJ
Mailing Address - Zip Code:07730-2024
Mailing Address - Country:US
Mailing Address - Phone:732-739-4666
Mailing Address - Fax:732-739-0236
Practice Address - Street 1:812 POOLE AVE
Practice Address - Street 2:SUITE D
Practice Address - City:HAZLET
Practice Address - State:NJ
Practice Address - Zip Code:07730-2024
Practice Address - Country:US
Practice Address - Phone:732-739-4666
Practice Address - Fax:732-739-0236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ509522OtherUNITEDHEALTHCARE
NJ2451525OtherAETNA US HEALTHCARE
NJ116115400OtherUS DEPT OF LABOR
NJ036820Medicare ID - Type Unspecified