=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972744753
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN DIGIAMBATTISTA DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2009
-----------------------------------------------------
Last Update Date | 03/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 N MAIN ST
-----------------------------------------------------
City | MOSCOW
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18444-9003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-842-8191
-----------------------------------------------------
Fax | 570-842-8192
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24569 ROUTE 6 SUITE C
-----------------------------------------------------
City | TOWANDA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18848-8254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-265-1111
-----------------------------------------------------
Fax | 570-265-7134
-----------------------------------------------------
=====================================================
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 | PT019831
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------