Provider Demographics
NPI:1437349131
Name:PROACTIVE PHYSICAL MEDICINE, LLC
Entity Type:Organization
Organization Name:PROACTIVE PHYSICAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:QUELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-321-3538
Mailing Address - Street 1:1331 E WYOMING AVE
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-3808
Mailing Address - Country:US
Mailing Address - Phone:215-744-4030
Mailing Address - Fax:215-744-4582
Practice Address - Street 1:1331 E WYOMING AVE
Practice Address - Street 2:SUITE 1100
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-3808
Practice Address - Country:US
Practice Address - Phone:215-744-4030
Practice Address - Fax:215-744-4582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-29
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty