Provider Demographics
NPI:1912390022
Name:GIBSONIA SPINE SPORT & HEALTH
Entity Type:Organization
Organization Name:GIBSONIA SPINE SPORT & HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:TALORICO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:724-709-3430
Mailing Address - Street 1:5499 WILLIAM FLYNN HWY
Mailing Address - Street 2:
Mailing Address - City:GIBSONIA
Mailing Address - State:PA
Mailing Address - Zip Code:15044-9675
Mailing Address - Country:US
Mailing Address - Phone:724-443-8444
Mailing Address - Fax:724-443-6963
Practice Address - Street 1:5499 WILLIAM FLYNN HWY
Practice Address - Street 2:
Practice Address - City:GIBSONIA
Practice Address - State:PA
Practice Address - Zip Code:15044-9675
Practice Address - Country:US
Practice Address - Phone:724-443-8444
Practice Address - Fax:724-443-6963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC06345L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1829811Medicaid
PA809656OtherBLUE SHIELD
PA214910OtherUPMC
PA214910OtherUPMC