Basic Information
| Provider Information | |||||||||
| NPI: | 1114316031 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IANNELLI | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | CARMEN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 EVES DR STE A100 | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080533126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092679400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 570 EGG HARBOR RD STE C4 | ||||||||
| Address2: | |||||||||
| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092679400 | ||||||||
| FaxNumber: | 6092679457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2015 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | J1-0003262 | DE | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 40QA01800800 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.