Provider Demographics
NPI:1558438754
Name:PHOENIX PHYSICAL THERAPY REHAB CTR
Entity Type:Organization
Organization Name:PHOENIX PHYSICAL THERAPY REHAB CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:ASHLEY
Authorized Official - Last Name:PREWITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-991-9911
Mailing Address - Street 1:PO BOX 26461
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-6461
Mailing Address - Country:US
Mailing Address - Phone:215-991-9911
Mailing Address - Fax:215-991-9913
Practice Address - Street 1:4943 GERMANTOWN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-5962
Practice Address - Country:US
Practice Address - Phone:215-991-9911
Practice Address - Fax:215-991-9913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT-006992-L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014008940001Medicaid
PA2228304000OtherKEYSTONE HEALTH PLAN EAST
PA690613OtherBLUECROSS
PA077743OtherMEDICARE
PA35998OtherHEALTH PARTNERS
PAPHI54368OtherHIGHMARK
PA0140089403OtherAMERICHOICE
PA1543468OtherPERSONAL CHOICE
PA3428119OtherAETNA
PA077743OtherMEDICARE