Provider Demographics
NPI:1689647950
Name:PROACTIVE OF PENNSYLVANIA PC
Entity Type:Organization
Organization Name:PROACTIVE OF PENNSYLVANIA PC
Other - Org Name:PROACTIVE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSCIAL THERAPY
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:HATHAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:607-227-6366
Mailing Address - Street 1:7325 OSWEGO RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-3717
Mailing Address - Country:US
Mailing Address - Phone:315-451-6541
Mailing Address - Fax:315-451-7059
Practice Address - Street 1:7325 OSWEGO RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-3717
Practice Address - Country:US
Practice Address - Phone:315-451-6541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT017496225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA093326UGXMedicare ID - Type Unspecified