Provider Demographics
NPI:1649210626
Name:GAGLIARDI, ANTHONY J (MPT)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:GAGLIARDI
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:779 W SPROUL RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-1215
Practice Address - Country:US
Practice Address - Phone:484-470-2150
Practice Address - Fax:610-328-9283
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10002335225100000X
PAPT008422L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11842861OtherCAQH
PA000643670OtherBLUE SHIELD
5070-0097OtherGHMSI
PA0237454000OtherBLUE CROSS
0237454000OtherIBC AMERIHEALTH
1649210626OtherCHAMPUS TRICARE
PA650021486OtherRAILROAD MEDICARE
DE1649210626Medicaid
93779901OtherCAREFIRST OF MD
PA0237454000OtherBLUE CROSS
93779901OtherCAREFIRST OF MD
PA650021486OtherRAILROAD MEDICARE