Provider Demographics
NPI:1487691168
Name:STAVROPOLSKIY, LEONARD (PT)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:
Last Name:STAVROPOLSKIY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 JAMISON AVE STE 222
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-3832
Mailing Address - Country:US
Mailing Address - Phone:215-676-3870
Mailing Address - Fax:
Practice Address - Street 1:10100 JAMISON AVE STE 222
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-3832
Practice Address - Country:US
Practice Address - Phone:215-676-3870
Practice Address - Fax:215-676-6856
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT015799225100000X
PADC007444L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101092010003Medicaid
PA066339SETMedicare PIN
PA101092010003Medicaid