Provider Demographics
NPI:1386832533
Name:RICHARDS, JEFFREY MARK (PT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:MARK
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 TURKEY RIDGE RD UNIT D
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-8233
Mailing Address - Country:US
Mailing Address - Phone:814-397-4050
Mailing Address - Fax:
Practice Address - Street 1:601 PARK ST
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-1445
Practice Address - Country:US
Practice Address - Phone:570-253-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT-001173-E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAED194700Medicare UPIN