Healthcare Provider Details

I. General information

NPI: 1093739559
Provider Name (Legal Business Name): BERNARD JOSEPH POVANDA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S MAIN ST
OLD FORGE PA
18518-1541
US

IV. Provider business mailing address

21 KIPLING DR
MOOSIC PA
18507-1933
US

V. Phone/Fax

Practice location:
  • Phone: 570-457-4099
  • Fax: 570-457-7225
Mailing address:
  • Phone: 570-344-9585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT005968L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier650012236
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE
# 2
Identifier072427
Identifier TypeOTHER
Identifier State
Identifier IssuerFIRST PRIORITY HEALTH
# 3
Identifier472307
Identifier TypeOTHER
Identifier State
Identifier IssuerAMERI HEALTH
# 4
Identifier235569
Identifier TypeOTHER
Identifier State
Identifier IssuerHEALTH AMERICA
# 5
Identifier472307Q69
Identifier TypeOTHER
Identifier State
Identifier IssuerSTERLING OPTIONS I
# 6
Identifier472307
Identifier TypeOTHER
Identifier State
Identifier IssuerHIGHMARK BLUE SHIELD
# 7
Identifier9357839
Identifier TypeOTHER
Identifier State
Identifier IssuerCIGNA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: