Healthcare Provider Details

I. General information

NPI: 1871011882
Provider Name (Legal Business Name): NICHOLAS PETROSKI DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12331 ACADEMY RD
PHILADELPHIA PA
19154-1927
US

IV. Provider business mailing address

12331 ACADEMY RD
PHILADELPHIA PA
19154-1927
US

V. Phone/Fax

Practice location:
  • Phone: 215-576-4796
  • Fax: 215-392-5175
Mailing address:
  • Phone: 215-576-4796
  • Fax: 215-392-5175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT026382
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT026382
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: