Provider Demographics
NPI:1518244565
Name:SOMERTON INDUSTRIAL MEDICINE & REHABILITATION, INC
Entity Type:Organization
Organization Name:SOMERTON INDUSTRIAL MEDICINE & REHABILITATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOEL
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:215-677-8870
Mailing Address - Street 1:12000 BUSTLETON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-2151
Mailing Address - Country:US
Mailing Address - Phone:215-677-8870
Mailing Address - Fax:215-673-9825
Practice Address - Street 1:12000 BUSTLETON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-2151
Practice Address - Country:US
Practice Address - Phone:215-677-8870
Practice Address - Fax:215-673-9825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT002807L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAN0005291342OtherAETNA