Basic Information
| Provider Information | |||||||||
| NPI: | 1992364582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSHAK | ||||||||
| FirstName: | BRENDAN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 DERRY ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171113576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178392125 | ||||||||
| FaxNumber: | 7175651104 | ||||||||
| Practice Location | |||||||||
| Address1: | 3250 HARDEN STREET EXT STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035096389 | ||||||||
| FaxNumber: | 8035096390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2019 | ||||||||
| LastUpdateDate: | 06/07/2019 | ||||||||
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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 | 9712 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.