Provider Demographics
NPI:1205886017
Name:MORTLAND, MARK R (PT/ATC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:MORTLAND
Suffix:
Gender:M
Credentials:PT/ATC
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:R
Other - Last Name:MORTLAND
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:154 SPRINGDALE RD
Mailing Address - Street 2:
Mailing Address - City:VENETIA
Mailing Address - State:PA
Mailing Address - Zip Code:15367-2361
Mailing Address - Country:US
Mailing Address - Phone:724-942-8990
Mailing Address - Fax:724-942-4461
Practice Address - Street 1:451 VALLEY BROOK RD
Practice Address - Street 2:
Practice Address - City:MC MURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-3353
Practice Address - Country:US
Practice Address - Phone:724-942-8990
Practice Address - Fax:724-942-4461
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT006410L208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation