Healthcare Provider Details

I. General information

NPI: 1235362708
Provider Name (Legal Business Name): ADVANCED PHYSICAL MEDICINE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2009
Last Update Date: 08/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 N MAIN ST
OLD FORGE PA
18518-1726
US

IV. Provider business mailing address

102 N MAIN ST
OLD FORGE PA
18518-1726
US

V. Phone/Fax

Practice location:
  • Phone: 570-451-1133
  • Fax: 570-451-0541
Mailing address:
  • Phone: 570-451-1133
  • Fax: 570-451-0541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. RAE MARIE JACQUELINE VENARUCCI
Title or Position: PRESIDENT
Credential: DC
Phone: 570-451-1133