Provider Demographics
NPI:1588676886
Name:GENTRY, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GENTRY
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 1:9589 LINCOLN HWY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BEDFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15522-3708
Mailing Address - Country:US
Mailing Address - Phone:814-623-9022
Mailing Address - Fax:814-623-6639
Practice Address - Street 1:9589 LINCOLN HWY
Practice Address - Street 2:SUITE 2
Practice Address - City:BEDFORD
Practice Address - State:PA
Practice Address - Zip Code:15522-3708
Practice Address - Country:US
Practice Address - Phone:814-623-9022
Practice Address - Fax:814-623-6639
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT015686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018982830004Medicaid
PA079251SR5Medicare ID - Type Unspecified