MEDICARE: BRIDESBURG SPINE AND INJURY CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	DC009115	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	117559	OTHER	PA	INDIVIDUAL MC ID

General Provider Information

NPI Number	:	1295143303
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDESBURG SPINE AND INJURY CLINIC LLC

Provider Business Mailing Address
First Line	:	2644 LEFEVRE ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19137-1733
Country	:	US
Telephone Number	:	215-743-5330
Fax Number	:	215-941-6441

Provider Business Practice Location Address
First Line	:	2644 LEFEVRE ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19137-1733
Country	:	US
Telephone Number	:	215-743-5330
Fax Number	:	215-941-6441

Authorized Official
Title or Position	:	OWNER CHIROPRACTOR
Name	:	ANTHONY P CALANTONI
Credential	:	DC
Telephone Number	:	215-743-5330

Provider Enumeration Date	:	08/01/2014
Last Update Date	:	08/01/2014

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