Provider Demographics
NPI:1861506594
Name:PETROSKY, GREGORY REGIS (PT)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:REGIS
Last Name:PETROSKY
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 1:5357 GRANT RD
Mailing Address - Street 2:
Mailing Address - City:RIDGWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15853-5707
Mailing Address - Country:US
Mailing Address - Phone:814-776-6351
Mailing Address - Fax:
Practice Address - Street 1:1 SOUTH ST
Practice Address - Street 2:
Practice Address - City:RIDGWAY
Practice Address - State:PA
Practice Address - Zip Code:15853-1817
Practice Address - Country:US
Practice Address - Phone:814-772-7848
Practice Address - Fax:814-772-7849
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT007531L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012126540001OtherMEDICAL ASSISTANCE
PA1012126540001OtherMEDICAL ASSISTANCE
PAS22760Medicare UPIN