MEDICARE: PERFORMANCE PHYSICAL THERAPY, PC

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	174400000X	Specialist	PT005873L	PA
2	261QP2000X	Physical Therapy Clinic/Center	PT005873L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1533587	OTHER	PA	BCBS

General Provider Information

NPI Number	:	1578756813
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFORMANCE PHYSICAL THERAPY, PC

Provider Business Mailing Address
First Line	:	2661 CLEARVIEW RD
Second Line	:
City	:	ALLISON PARK
State	:	PA
Zip	:	15101-3180
Country	:	US
Telephone Number	:	412-492-8691
Fax Number	:

Provider Business Practice Location Address
First Line	:	2661 CLEARVIEW RD
Second Line	:
City	:	ALLISON PARK
State	:	PA
Zip	:	15101-3180
Country	:	US
Telephone Number	:	412-492-8691
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RICHARD B LYON
Credential	:	PT
Telephone Number	:	412-492-8691

Provider Enumeration Date	:	08/21/2007
Last Update Date	:	12/21/2010

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