Provider Demographics
NPI:1063595007
Name:PAOLI SPORTS MEDICINE AND REHABILITATION CENTER, INC.
Entity type:Organization
Organization Name:PAOLI SPORTS MEDICINE AND REHABILITATION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CORCORAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:610-647-1996
Mailing Address - Street 1:30 S VALLEY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1450
Mailing Address - Country:US
Mailing Address - Phone:610-647-1996
Mailing Address - Fax:610-408-8677
Practice Address - Street 1:30 S VALLEY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1469
Practice Address - Country:US
Practice Address - Phone:610-647-1996
Practice Address - Fax:610-408-8677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT-000620-E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1173150001OtherDME NUMBER
PA8495471OtherAETNA ID NUMBER
PADB4763OtherRR MEDICARE NUMBER
PA=========002OtherTRICARE PROVIDER NUMBER
PA1173150001OtherDME NUMBER