Provider Demographics
NPI:1336320209
Name:WOODLYN PHYSICAL THERAPY
Entity Type:Organization
Organization Name:WOODLYN PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKERNAN
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:302-738-4909
Mailing Address - Street 1:1082 OLD CHURCHMANS RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2143
Mailing Address - Country:US
Mailing Address - Phone:302-738-4909
Mailing Address - Fax:302-738-4905
Practice Address - Street 1:1082 OLD CHURCHMANS RD
Practice Address - Street 2:SUITE 101
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2143
Practice Address - Country:US
Practice Address - Phone:302-738-4909
Practice Address - Fax:302-738-4905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0000806225100000X
DEJ1-0001588225100000X
DEJ1-0002002225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEG01378Medicare PIN