=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821053281
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEITH A WOBESER IV P.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2006
-----------------------------------------------------
Last Update Date | 02/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 57 W EAGLE RD
-----------------------------------------------------
City | HAVERTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19083-2234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-987-9887
-----------------------------------------------------
Fax | 610-987-9883
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 BLACK ROCK RD
-----------------------------------------------------
City | GLADWYNE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19035-1407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-506-9322
-----------------------------------------------------
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 | PT011767L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------