Provider Demographics
NPI:1205890597
Name:REITZ, MARK E (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:REITZ
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 1:2010 WEST CHESTER PIKE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083
Mailing Address - Country:US
Mailing Address - Phone:610-853-0508
Mailing Address - Fax:610-853-3837
Practice Address - Street 1:2010 WEST CHESTER PIKE
Practice Address - Street 2:SUITE 450
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083
Practice Address - Country:US
Practice Address - Phone:610-853-0508
Practice Address - Fax:610-853-3837
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT003694L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA4495223OtherAETNA PROVIDER #
PA0033455000OtherINDEPENDENCE BLUE CROSS #