Provider Demographics
NPI:1598999351
Name:DREXEL UNIVERSITY
Entity Type:Organization
Organization Name:DREXEL UNIVERSITY
Other - Org Name:DREXEL UNIVERSITY PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE CHAIR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GARD
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, OCS
Authorized Official - Phone:215-762-7460
Mailing Address - Street 1:245 N 15TH ST # MS 502
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1101
Mailing Address - Country:US
Mailing Address - Phone:215-762-7460
Mailing Address - Fax:215-762-1175
Practice Address - Street 1:245 N 15TH ST # MS 502
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1101
Practice Address - Country:US
Practice Address - Phone:215-762-7460
Practice Address - Fax:215-762-1175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-08
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT007722L261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1127435OtherFIRST HEALTH
PA30017828OtherKEYSTONE MERCY HEALTH PLAN
PA3054841OtherAETNA
PA342212OtherBC/BS