Provider Demographics
NPI:1619285517
Name:POLKABLA, KEVIN A (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:POLKABLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GREENVILLE ORTHOPEDIC CTR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-1254
Mailing Address - Country:US
Mailing Address - Phone:724-588-9680
Mailing Address - Fax:724-588-9697
Practice Address - Street 1:4 GREENVILLE ORTHOPEDIC CTR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125-1254
Practice Address - Country:US
Practice Address - Phone:724-588-9680
Practice Address - Fax:724-588-9697
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT020880225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist