Provider Demographics
NPI:1649430638
Name:MARSICO, SAMUEL (PT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:MARSICO
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2022 E OLD LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-3002
Practice Address - Country:US
Practice Address - Phone:215-891-5150
Practice Address - Fax:215-891-1410
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10002368225100000X
PAPT019681225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
94292301OtherCAREFIRST
DE1649430638Medicaid
3535006000OtherIBC
5070-0107OtherGHMSI
129263Y0XMedicare PIN
3535006000OtherIBC