Provider Demographics
NPI:1992872923
Name:OSADCHEY, MARK LOWELL (RPT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:LOWELL
Last Name:OSADCHEY
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3914
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3914
Mailing Address - Country:US
Mailing Address - Phone:208-520-4041
Mailing Address - Fax:208-745-9477
Practice Address - Street 1:3310 VALENCIA DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7502
Practice Address - Country:US
Practice Address - Phone:208-520-4041
Practice Address - Fax:208-745-9477
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-10012251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1375073Medicare ID - Type UnspecifiedMEDICARE IDENTIFICATION
IDP00016855Medicare ID - Type UnspecifiedMEDICARE RAILROAD CARRIER
ID1654693Medicare ID - Type UnspecifiedPERFORMING PROVIDER #