Healthcare Provider Details

I. General information

NPI: 1326054750
Provider Name (Legal Business Name): PHYSICAL THERAPY ASSOCIATES OF NORTHEAST PENNSYLVANIA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S MAIN ST
OLD FORGE PA
18518
US

IV. Provider business mailing address

501 S MAIN ST
OLD FORGE PA
18518
US

V. Phone/Fax

Practice location:
  • Phone: 570-457-4099
  • Fax: 570-457-7205
Mailing address:
  • Phone: 570-457-4099
  • Fax: 570-457-7205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier539342
Identifier TypeOTHER
Identifier State
Identifier IssuerAETNA
# 2
Identifier24765
Identifier TypeOTHER
Identifier State
Identifier IssuerGEISINGER HEALTH PLAN
# 3
Identifier6699675
Identifier TypeOTHER
Identifier State
Identifier IssuerGHD
# 4
Identifier1677247
Identifier TypeOTHER
Identifier State
Identifier IssuerHIGHMARK

VIII. Authorized Official

Name: MR. BERNARD J. POVANDA
Title or Position: OWNER/PRESIDENT
Credential: PT
Phone: 570-457-4099