=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528681996
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES TERSAK DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2020
-----------------------------------------------------
Last Update Date | 05/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2751 O'VARSITY WAY ROOM 265
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45221-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-556-3178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2097 NOBLESTOWN RD
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15205-3826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-335-7853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT018542
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------