Provider Demographics
NPI:1770736308
Name:PONDER, MAIGHDLIN A (PT)
Entity type:Individual
Prefix:MRS
First Name:MAIGHDLIN
Middle Name:A
Last Name:PONDER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 5TH ST. NE
Mailing Address - Street 2:
Mailing Address - City:BARBERTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203
Mailing Address - Country:US
Mailing Address - Phone:865-512-1140
Mailing Address - Fax:865-512-1141
Practice Address - Street 1:28 CONSERVATORY DR. STE A
Practice Address - Street 2:
Practice Address - City:BARBERTON
Practice Address - State:OH
Practice Address - Zip Code:44203
Practice Address - Country:US
Practice Address - Phone:330-615-5000
Practice Address - Fax:330-848-3982
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8216225100000X
OH021585225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1510177Medicaid
TN4208823OtherBLUECROSS BLUESHEILD
P00746747OtherRAILROAD MEDICARE
TN3650209Medicare PIN