Provider Demographics
NPI:1902872773
Name:TANNERSVILLE PHYSICAL THERAPY & WELLNESS, INC.
Entity type:Organization
Organization Name:TANNERSVILLE PHYSICAL THERAPY & WELLNESS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:GEORGINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:TODD
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:570-629-4921
Mailing Address - Street 1:PO BOX 221
Mailing Address - Street 2:
Mailing Address - City:REEDERS
Mailing Address - State:PA
Mailing Address - Zip Code:18352-0221
Mailing Address - Country:US
Mailing Address - Phone:570-629-4921
Mailing Address - Fax:570-629-9221
Practice Address - Street 1:2313 ROUTE 715
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360
Practice Address - Country:US
Practice Address - Phone:570-629-4921
Practice Address - Fax:570-629-9221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013394L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA094584Medicare ID - Type UnspecifiedGROUP MEDICARE
PA054231Medicare ID - Type UnspecifiedGEORGINE MEDICARE