Healthcare Provider Details

I. General information

NPI: 1861506594
Provider Name (Legal Business Name): GREGORY REGIS PETROSKY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SOUTH ST
RIDGWAY PA
15853-1817
US

IV. Provider business mailing address

5357 GRANT RD
RIDGWAY PA
15853-5707
US

V. Phone/Fax

Practice location:
  • Phone: 814-772-7848
  • Fax: 814-772-7849
Mailing address:
  • Phone: 814-776-6351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT007531L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: