Provider Demographics
NPI:1396761904
Name:BRYN MAWR SPORTS MEDICINE AND REHABILITATION
Entity type:Organization
Organization Name:BRYN MAWR SPORTS MEDICINE AND REHABILITATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEUBER
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:610-525-1223
Mailing Address - Street 1:945 E HAVERFORD RD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3814
Mailing Address - Country:US
Mailing Address - Phone:610-525-1223
Mailing Address - Fax:610-525-5797
Practice Address - Street 1:945 E HAVERFORD RD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3814
Practice Address - Country:US
Practice Address - Phone:610-525-1223
Practice Address - Fax:610-525-5797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT003474L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA042752Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER