Healthcare Provider Details

I. General information

NPI: 1992938096
Provider Name (Legal Business Name): MARYJANE FEDORCZYK PT. PHD, CHT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANE FEDORCZYK PT. PHD, CHT, ATC

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 08/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 N 15TH ST MAIL STOP 502
PHILADELPHIA PA
19102-1101
US

IV. Provider business mailing address

245 N 15TH ST MAIL STOP 502
PHILADELPHIA PA
19102-1101
US

V. Phone/Fax

Practice location:
  • Phone: 215-762-4680
  • Fax:
Mailing address:
  • Phone: 215-762-4680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License NumberPT006083L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License Number40QA00546800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: