Provider Demographics
NPI:1821053281
Name:WOBESER, KEITH A IV (PT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:A
Last Name:WOBESER
Suffix:IV
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 1:1000 BLACK ROCK RD
Mailing Address - Street 2:
Mailing Address - City:GLADWYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19035-1407
Mailing Address - Country:US
Mailing Address - Phone:610-506-9322
Mailing Address - Fax:
Practice Address - Street 1:57 W EAGLE RD
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2234
Practice Address - Country:US
Practice Address - Phone:610-987-9887
Practice Address - Fax:610-987-9883
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT011767L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3204065OtherAETNA HMO PROVIDER #
PA7680482OtherAETNA TRADITIONAL PROV. #
PAWO1466561OtherBC/BS PROVIDER #
PAP00433225OtherMEDICARE RAILROAD PIN
PA2150818000OtherPERSONAL CHOICE PIN
PA2150818000OtherKEYSTONE PIN
PA3204065OtherAETNA HMO PROVIDER #