Provider Demographics
NPI:1841224839
Name:ROYAL, MARVIN P II (PT)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:P
Last Name:ROYAL
Suffix:II
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 1:200 TUCKERTON RD
Mailing Address - Street 2:SUITE 17
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-8806
Mailing Address - Country:US
Mailing Address - Phone:856-396-2250
Mailing Address - Fax:856-810-0373
Practice Address - Street 1:200 TUCKERTON RD
Practice Address - Street 2:SUITE 17
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-8806
Practice Address - Country:US
Practice Address - Phone:856-396-2250
Practice Address - Fax:856-810-0373
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007772225100000X
NJ40QA01427700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650001214Medicare ID - Type Unspecified