=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144452251
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROSSBRIDGE PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2009
-----------------------------------------------------
Last Update Date | 08/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 568 FRANKLIN ST
-----------------------------------------------------
City | CLYMER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15728-1183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-254-2526
-----------------------------------------------------
Fax | 724-254-2527
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1139 TANOMA RD
-----------------------------------------------------
City | INDIANA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15701-7000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-719-4166
-----------------------------------------------------
Fax | 724-254-2527
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF PHYSICAL THERAPY
-----------------------------------------------------
Name | DR. BRANDON LEE HAGGERTY
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 724-254-2526
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 016695
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------