Basic Information
| Provider Information | |||||||||
| NPI: | 1023017126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRANZA | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | ALBERTO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2775 SCHOENERSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180177307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108618080 | ||||||||
| FaxNumber: | 6108070366 | ||||||||
| Practice Location | |||||||||
| Address1: | 2775 SCHOENERSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180177307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108618080 | ||||||||
| FaxNumber: | 6108070366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 01/10/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT008017L | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P1643780 | 01 | OXFORD HEALTH PLANS | OTHER | 748181 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 0690022000 | 01 | AMERIHEALTH | OTHER | 328979 | 01 | HEALTHAMERICA/HEALTHASSUR | OTHER | 02093301 | 01 | KEYSTONE HEALTH CENTRAL | OTHER | 4854485 | 01 | CIGNA HEALTHCARE | OTHER | 02093301 | 01 | CAPITAL BLUE CROSS | OTHER | 0467891 | 01 | AETNA PPO | OTHER | 0690022000 | 01 | INDEPENDENCE BLUE CROSS | OTHER | 821764 | 01 | FIRST PRIORITY HEALTH | OTHER | 1398661 | 01 | UNITED HEALTHCARE | OTHER | 2170551 | 01 | MAMSI | OTHER | 0690022000 | 01 | KEYSTONE HEALTH EAST | OTHER |