MEDICARE: AQUATIC THERAPY OF CHINATOWN

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	PT015799	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2155332000	OTHER	PA	KEYSTONE HEALTH PLAN EAST

General Provider Information

NPI Number	:	1639107071
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AQUATIC THERAPY OF CHINATOWN

Provider Business Mailing Address
First Line	:	7300 BRUCE DRIVE
Second Line	:
City	:	HOLLAND
State	:	PA
Zip	:	18966
Country	:	US
Telephone Number	:	215-703-3275
Fax Number	:

Provider Business Practice Location Address
First Line	:	933 SPRING ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-1815
Country	:	US
Telephone Number	:	215-574-9388
Fax Number	:	215-574-9188

Authorized Official
Title or Position	:	PHYSICAL THERAPY/OWNER
Name	:	LEONARD STAVROPOLSKIY
Credential	:	MD
Telephone Number	:	215-574-9388

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	08/22/2020

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Directions to “AQUATIC THERAPY OF CHINATOWN ” Practice Location

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