Provider Demographics
NPI:1457310666
Name:EBERLE, MARK THOMAS (PT ATC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:THOMAS
Last Name:EBERLE
Suffix:
Gender:M
Credentials:PT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 WALKER DR
Mailing Address - Street 2:
Mailing Address - City:EDINBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16412-2237
Mailing Address - Country:US
Mailing Address - Phone:814-734-7444
Mailing Address - Fax:814-734-8509
Practice Address - Street 1:103 WALKER DR
Practice Address - Street 2:
Practice Address - City:EDINBORO
Practice Address - State:PA
Practice Address - Zip Code:16412-2237
Practice Address - Country:US
Practice Address - Phone:814-734-7444
Practice Address - Fax:814-734-8509
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT006496L225100000X
PART000110A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015328200004Medicaid
071294RW0Medicare ID - Type Unspecified
PA0015328200004Medicaid