Provider Demographics
NPI:1679841415
Name:WILLIAMSPORT PHYSICAL MEDICINE, INC.
Entity type:Organization
Organization Name:WILLIAMSPORT PHYSICAL MEDICINE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:J
Authorized Official - Last Name:FORTE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-287-5560
Mailing Address - Street 1:1101 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-5411
Mailing Address - Country:US
Mailing Address - Phone:570-322-5500
Mailing Address - Fax:570-322-8100
Practice Address - Street 1:1101 E 3RD ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-5411
Practice Address - Country:US
Practice Address - Phone:570-322-5500
Practice Address - Fax:570-322-8100
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIAMSPORT PHYSICAL MEDICINE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-08
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD433098208D00000X
PA332B00000X
PAMA052411363A00000X
PARN523038L363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2081099OtherBLUE CROSS BLUE SHIELD
PA2081099OtherBLUE CROSS BLUE SHIELD