Provider Demographics
NPI:1578545125
Name:BOLAND, MARK ANDREW (MPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:BOLAND
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 FRANCISCAN WAY
Mailing Address - Street 2:DISEPIO CENTER FOR REHABILITATION
Mailing Address - City:LORETTO
Mailing Address - State:PA
Mailing Address - Zip Code:15940
Mailing Address - Country:US
Mailing Address - Phone:814-472-3936
Mailing Address - Fax:814-472-3905
Practice Address - Street 1:108 FRANCISCAN WAY
Practice Address - Street 2:DISEPIO CENTER FOR REHABILITATION
Practice Address - City:LORETTO
Practice Address - State:PA
Practice Address - Zip Code:15940
Practice Address - Country:US
Practice Address - Phone:814-472-3936
Practice Address - Fax:814-472-3905
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT016327225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1584800OtherHIGHMARK
PAP00068406OtherRR MEDICARE
PAP00068406OtherRR MEDICARE
PA1584800OtherHIGHMARK