Healthcare Provider Details

I. General information

NPI: 1578165403
Provider Name (Legal Business Name): CODY JAMES HEGEDUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 BLOOMFIELD ST
JOHNSTOWN PA
15904-3271
US

IV. Provider business mailing address

514 N MARIAN ST
EBENSBURG PA
15931-1216
US

V. Phone/Fax

Practice location:
  • Phone: 814-269-2224
  • Fax:
Mailing address:
  • Phone: 814-241-8703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT026257
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: