MEDICARE: JOHN H LACOBOULOS PT

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	PT013028L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0017783000	OTHER	PA	IBC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	338203	OTHER	PA	HIGHMARK BLUE SHIELD

General Provider Information

NPI Number	:	1881668226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN H LACOBOULOS PT

Provider Business Mailing Address
First Line	:	1401 CHESTER PIKE
Second Line	:
City	:	EDDYSTONE
State	:	PA
Zip	:	19022-1336
Country	:	US
Telephone Number	:	866-557-9430
Fax Number	:	866-557-9431

Provider Business Practice Location Address
First Line	:	1401 CHESTER PIKE
Second Line	:
City	:	EDDYSTONE
State	:	PA
Zip	:	19022-1336
Country	:	US
Telephone Number	:	866-557-9430
Fax Number	:	866-557-9431

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2006
Last Update Date	:	08/16/2011

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