Provider Demographics
NPI:1568131688
Name:SISTRUN, MARCUS HOWARD
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:HOWARD
Last Name:SISTRUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 E DURHAM ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-1223
Mailing Address - Country:US
Mailing Address - Phone:215-870-7984
Mailing Address - Fax:
Practice Address - Street 1:2301 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132-4534
Practice Address - Country:US
Practice Address - Phone:215-228-2656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-11
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT029731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist