Provider Demographics
NPI:1063588093
Name:PHYSICAL THERAPY AND REHABILITATION CLINIC INC
Entity type:Organization
Organization Name:PHYSICAL THERAPY AND REHABILITATION CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:J
Authorized Official - Last Name:RASICCI
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:724-947-9999
Mailing Address - Street 1:1569 SMITH TOWNSHIP STATE ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ATLASBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15004
Mailing Address - Country:US
Mailing Address - Phone:724-947-9999
Mailing Address - Fax:740-264-4376
Practice Address - Street 1:1569 SMITH TOWNSHIP STATE ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:ATLASBURG
Practice Address - State:PA
Practice Address - Zip Code:15004
Practice Address - Country:US
Practice Address - Phone:724-947-9999
Practice Address - Fax:740-264-4376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT001148E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019673260001Medicaid
PA485432OtherBLUE CROSS BLUE SHIELD
PA485432OtherBLUE CROSS BLUE SHIELD
PA=========OtherTAX IDENTIFICATION