Provider Demographics
NPI:1326054750
Name:PHYSICAL THERAPY ASSOCIATES OF NORTHEAST PENNSYLVANIA INC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY ASSOCIATES OF NORTHEAST PENNSYLVANIA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:POVANDA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:570-457-4099
Mailing Address - Street 1:501 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518
Mailing Address - Country:US
Mailing Address - Phone:570-457-4099
Mailing Address - Fax:570-457-7205
Practice Address - Street 1:501 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518
Practice Address - Country:US
Practice Address - Phone:570-457-4099
Practice Address - Fax:570-457-7205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
539342OtherAETNA
24765OtherGEISINGER HEALTH PLAN
6699675OtherGHD
1677247OtherHIGHMARK
6699675OtherGHD