Provider Demographics
NPI:1639214091
Name:KANE, BRYAN ALAN (OT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:ALAN
Last Name:KANE
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 SHELMIRE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136-3523
Mailing Address - Country:US
Mailing Address - Phone:215-840-7134
Mailing Address - Fax:
Practice Address - Street 1:2716 ORTHODOX ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19137-1604
Practice Address - Country:US
Practice Address - Phone:215-743-4435
Practice Address - Fax:215-743-8848
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC008444225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA088348PQXMedicare ID - Type Unspecified