Provider Demographics
NPI:1104250539
Name:SHIDEMANTLE, BRIAN R (DPT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:SHIDEMANTLE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BRADFORD RD
Mailing Address - Street 2:STE 210
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-8485
Mailing Address - Country:US
Mailing Address - Phone:724-602-0747
Mailing Address - Fax:724-604-8022
Practice Address - Street 1:100 BRADFORD RD
Practice Address - Street 2:STE 210
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090
Practice Address - Country:US
Practice Address - Phone:724-940-2323
Practice Address - Fax:724-940-2340
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305208250225100000X
PAPT022955225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist