Provider Demographics
NPI:1538217682
Name:PISAREK, BRUCE (MPT)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:PISAREK
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 DONERAIL AVE
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-9138
Mailing Address - Country:US
Mailing Address - Phone:614-218-6597
Mailing Address - Fax:
Practice Address - Street 1:698 MORRISON RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-4419
Practice Address - Country:US
Practice Address - Phone:614-868-1115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT008426225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2698335Medicaid
OH2698335Medicaid