Mark    Mascio    RPT
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000005607
NPI
1912918079
Tax ID
550719300
Effective Date
4/1/2012
Last Updated
10/21/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
92.00
Location Details
Address
414 Penco Road
Weirton, WV 26062
United States
County
Hancock
Phone
3047233780 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Physical Therapy
Map
Address