Provider Demographics
NPI:1881710572
Name:SHAGINAW, JUSTIN WILLIAM (MPT, ATC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WILLIAM
Last Name:SHAGINAW
Suffix:
Gender:M
Credentials:MPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8500-1672
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-1672
Mailing Address - Country:US
Mailing Address - Phone:215-409-9300
Mailing Address - Fax:215-409-9368
Practice Address - Street 1:3110 GRANT AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-2542
Practice Address - Country:US
Practice Address - Phone:215-409-9300
Practice Address - Fax:215-409-9368
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT009705L225100000X
PART0033372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA8801588OtherAETNA PPO
PA082787OtherHIGHMARK BLUE SHIELD