Provider Demographics
NPI:1669184578
Name:VIA AFFILIATES
Entity type:Organization
Organization Name:VIA AFFILIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR EXECUTIVE - DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-345-2389
Mailing Address - Street 1:PO BOX 829641
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-9641
Mailing Address - Country:US
Mailing Address - Phone:267-370-5285
Mailing Address - Fax:215-230-3725
Practice Address - Street 1:2189 SECOND STREET PIKE STE 200
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-4134
Practice Address - Country:US
Practice Address - Phone:215-345-0105
Practice Address - Fax:215-345-0562
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VIA AFFILIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-22
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty