Basic Information
Provider Information
NPI: 1689652497
EntityType: 2
ReplacementNPI:  
OrganizationName: LYCOMING PHYSICAL THERAPY
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1009 BROAD STREET
Address2:  
City: MONTOURSVILLE
State: PA
PostalCode: 17754
CountryCode: US
TelephoneNumber: 5703688389
FaxNumber: 5703688391
Practice Location
Address1: 1009 BROAD STREET
Address2:  
City: MONTOURSVILLE
State: PA
PostalCode: 17754
CountryCode: US
TelephoneNumber: 5703688389
FaxNumber: 5703688391
Other Information
ProviderEnumerationDate: 01/03/2006
LastUpdateDate: 01/09/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: BURGER
AuthorizedOfficialFirstName: ROBERT
AuthorizedOfficialMiddleName: J
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 5703688389
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: PT
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X  Y193400000X SINGLE SPECIALTY GROUPRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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