Provider Demographics
NPI:1558322859
Name:EAST REHABILITATION PA
Entity Type:Organization
Organization Name:EAST REHABILITATION PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:EAST
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-380-0000
Mailing Address - Street 1:16633 DALLAS PKWY STE 150
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-6812
Mailing Address - Country:US
Mailing Address - Phone:972-380-0000
Mailing Address - Fax:972-380-0030
Practice Address - Street 1:16633 DALLAS PKWY STE 150
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-6812
Practice Address - Country:US
Practice Address - Phone:972-380-0000
Practice Address - Fax:972-380-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X, 208100000X, 2081P2900X
TXM1138207Q00000X
TXP8718207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154668101Medicaid
TX154668101Medicaid