Provider Demographics
NPI:1881667467
Name:BAILEY, GORDON R (PT)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:R
Last Name:BAILEY
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 1:512 E COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:CORRY
Mailing Address - State:PA
Mailing Address - Zip Code:16407-9014
Mailing Address - Country:US
Mailing Address - Phone:814-664-9346
Mailing Address - Fax:814-663-0169
Practice Address - Street 1:512 E COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:CORRY
Practice Address - State:PA
Practice Address - Zip Code:16407-9014
Practice Address - Country:US
Practice Address - Phone:814-664-9346
Practice Address - Fax:814-663-0169
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT009652L174400000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00025292701OtherLEGACY NUMBER - UNIVERA
PA457211OtherLEGACY NUMBER - HIGHMARK
NY9390591OtherLEGACY NUMBER - IND. HEAL
NY9390591OtherLEGACY NUMBER - IND. HEAL