MEDICARE: AQUAHAB, LP

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	:	1255330908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AQUAHAB, LP

Provider Business Mailing Address
First Line	:	3600 GRANT AVENUE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19114
Country	:	US
Telephone Number	:	856-751-5177
Fax Number	:	856-751-5489

Provider Business Practice Location Address
First Line	:	3600 GRANT AVE
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19114-2630
Country	:	US
Telephone Number	:	215-677-0400
Fax Number	:	215-671-1837

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	MS. CHRISTINA GORMAN
Credential	:
Telephone Number	:	856-751-5177

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	06/19/2017

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