Basic Information
| Provider Information | |||||||||
| NPI: | 1649284977 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EISENHOFER | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | DPT, OCS, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 36TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261011005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049173660 | ||||||||
| FaxNumber: | 3049173674 | ||||||||
| Practice Location | |||||||||
| Address1: | 5479 POTTSVILLE PIKE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LEESPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 195338650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109266778 | ||||||||
| FaxNumber: | 6109267200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 05/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 002261 | WV | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT019473 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2617663 | 05 | OH | MEDICAID | 3810003931 | 05 | WV | MEDICAID | P00033898 | 01 | RAILROAD MEDICARE | OTHER | 1022270250001 | 05 | PA | MEDICAID |