=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992838643
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTERN SHORE PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 09/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1999 NEW RD SUITE C
-----------------------------------------------------
City | LINWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08221-1060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-601-6140
-----------------------------------------------------
Fax | 609-601-6141
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 751
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08225-0751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-601-6140
-----------------------------------------------------
Fax | 609-601-6141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSEPH THOMAS DEROSA
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 609-601-6140
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 40QA00872300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------