Provider Demographics
NPI:1710923776
Name:WILDE, STEVEN R (PT)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:R
Last Name:WILDE
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 1:518 PELLLIS RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-4599
Mailing Address - Country:US
Mailing Address - Phone:724-832-1696
Mailing Address - Fax:724-832-6351
Practice Address - Street 1:6970 FOX HUNT LN
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-5394
Practice Address - Country:US
Practice Address - Phone:804-694-8111
Practice Address - Fax:804-694-5574
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052140442225100000X
PAPT003818L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000424032OtherHIGHMARK
4625101OtherAETNA US HEALTHCARE
4625101OtherAETNA US HEALTHCARE