Provider Demographics
NPI:1942923693
Name:REGENERATIVE PHYSICAL MEDICINE LLC
Entity Type:Organization
Organization Name:REGENERATIVE PHYSICAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:H
Authorized Official - Last Name:UNDERDOWN
Authorized Official - Suffix:
Authorized Official - Credentials:SOLE MBR
Authorized Official - Phone:570-772-5362
Mailing Address - Street 1:1111 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-5411
Mailing Address - Country:US
Mailing Address - Phone:570-772-5362
Mailing Address - Fax:
Practice Address - Street 1:250 PIERCE ST STE 103
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5149
Practice Address - Country:US
Practice Address - Phone:570-287-1110
Practice Address - Fax:570-287-1121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty