Provider Demographics
NPI:1336181619
Name:NORTHWESTERN PHYSICAL THERAPY SERVICE, INC.
Entity type:Organization
Organization Name:NORTHWESTERN PHYSICAL THERAPY SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:814-827-2347
Mailing Address - Street 1:202 UNION ST
Mailing Address - Street 2:P O BOX 381
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354-1160
Mailing Address - Country:US
Mailing Address - Phone:814-827-2347
Mailing Address - Fax:814-827-2391
Practice Address - Street 1:202 UNION ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354-1160
Practice Address - Country:US
Practice Address - Phone:814-827-2347
Practice Address - Fax:814-827-2391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PANO412827OtherHIGHMARK BC/BS I.D.
PA0014374730005Medicaid
PA0014374730005Medicaid