Basic Information
Provider Information
NPI: 1639132954
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GILLEN
FirstName: JOHN
MiddleName: FRANCES
NamePrefix:  
NameSuffix: JR.
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: 505 INDEPENDENCE RD
Address2: SUITE A
City: EAST STROUDSBURG
State: PA
PostalCode: 183017916
CountryCode: US
TelephoneNumber: 5704208080
FaxNumber: 5704201704
Other Information
ProviderEnumerationDate: 04/08/2006
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: X
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000XPT003423LPAY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


Home