Provider Demographics
NPI:1023420460
Name:GARNET VALLEY SPORT & SPINE PHYSICAL MEDICINE, INC.
Entity type:Organization
Organization Name:GARNET VALLEY SPORT & SPINE PHYSICAL MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:610-361-0070
Mailing Address - Street 1:3039 FOULK RD
Mailing Address - Street 2:
Mailing Address - City:GARNET VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19060-1701
Mailing Address - Country:US
Mailing Address - Phone:610-361-0070
Mailing Address - Fax:610-361-0071
Practice Address - Street 1:3039 FOULK RD
Practice Address - Street 2:
Practice Address - City:GARNET VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19060-1701
Practice Address - Country:US
Practice Address - Phone:610-361-0070
Practice Address - Fax:610-361-0071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-008262-L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty