Provider Demographics
NPI:1780803882
Name:WOODLYN PHYSICAL THERAPY
Entity type:Organization
Organization Name:WOODLYN PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKERNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-583-1133
Mailing Address - Street 1:412 MACDADE BLVD
Mailing Address - Street 2:
Mailing Address - City:MILMONT PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19033-3300
Mailing Address - Country:US
Mailing Address - Phone:610-583-1133
Mailing Address - Fax:610-583-0855
Practice Address - Street 1:412 MACDADE BLVD
Practice Address - Street 2:
Practice Address - City:MILMONT PARK
Practice Address - State:PA
Practice Address - Zip Code:19033-3300
Practice Address - Country:US
Practice Address - Phone:610-583-1133
Practice Address - Fax:610-583-0855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT017756225100000X
PAPT007239L225100000X
DEJ10001588225100000X
DEJ10002002225100000X
DEJ10000806225100000X
PAPT008005L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA077745Medicare ID - Type UnspecifiedGROUP NUMBER