MEDICARE: PENNSPORT PHYSICAL THERAPY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1023018793
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENNSPORT PHYSICAL THERAPY INC

Provider Business Mailing Address
First Line	:	2101 S COLUMBUS BLVD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19148-2805
Country	:	US
Telephone Number	:	215-467-4431
Fax Number	:	215-467-8879

Provider Business Practice Location Address
First Line	:	2101 S COLUMBUS BLVD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19148-2805
Country	:	US
Telephone Number	:	215-467-4431
Fax Number	:	215-467-8879

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL A DELUCA
Credential	:	PT
Telephone Number	:	215-467-4431

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	11/19/2012

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