Provider Demographics
NPI:1477542298
Name:MALLOY, PHILIP (LPT)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:MALLOY
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 WOODGLEN RD
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-1335
Mailing Address - Country:US
Mailing Address - Phone:570-622-6648
Mailing Address - Fax:570-628-4709
Practice Address - Street 1:2655 WOODGLEN RD
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-1335
Practice Address - Country:US
Practice Address - Phone:570-622-6648
Practice Address - Fax:570-628-4709
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT003353L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA075961OtherBLUE SHIELD
PA01505402OtherCAPITAL
PA484428OtherAETNA
PAR05935Medicare UPIN
PA484428OtherAETNA