Provider Demographics
NPI:1699731505
Name:TARANTA, MARK VICTOR (PT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:VICTOR
Last Name:TARANTA
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 1:1800 LOMBARD ST
Mailing Address - Street 2:SUITE 805 PEPPER PAVILION
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19164-1497
Mailing Address - Country:US
Mailing Address - Phone:215-893-7595
Mailing Address - Fax:215-893-2721
Practice Address - Street 1:1800 LOMBARD ST
Practice Address - Street 2:SUITE 805 PEPPER PAVILION
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19164-1497
Practice Address - Country:US
Practice Address - Phone:215-893-7595
Practice Address - Fax:215-893-2721
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT006134L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1047061Medicaid
PATA556631Medicare ID - Type Unspecified
R07392Medicare UPIN