Provider Demographics
NPI:1497227755
Name:GRIVNOVICS, ALEXANDER (PTA)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:GRIVNOVICS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1938 E MOYAMENSING AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-2527
Mailing Address - Country:US
Mailing Address - Phone:267-847-4741
Mailing Address - Fax:
Practice Address - Street 1:535 GRADYVILLE RD
Practice Address - Street 2:
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-2812
Practice Address - Country:US
Practice Address - Phone:610-558-5053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI004419225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant