Provider Demographics
NPI:1912962812
Name:FAVA, CRAIG S (PT)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:S
Last Name:FAVA
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 1:140 OAKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-2112
Mailing Address - Country:US
Mailing Address - Phone:610-565-1671
Mailing Address - Fax:
Practice Address - Street 1:727 S CHESTER RD
Practice Address - Street 2:
Practice Address - City:SWARTHMORE
Practice Address - State:PA
Practice Address - Zip Code:19081-2710
Practice Address - Country:US
Practice Address - Phone:610-543-4605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT-011552-L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00872660000OtherPERSONAL CHOICE
PA7148219OtherAETNA TRADITIONAL #
PA2582353OtherAETNA HMO
PA00872660000OtherPERSONAL CHOICE