Basic Information
| Provider Information | |||||||||
| NPI: | 1043347735 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSIOTHERAPY ASSOCIATES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHYSIOTHERAPY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 665 PHILADELPHIA ST | ||||||||
| Address2: | |||||||||
| City: | INDIANA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157013941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7244653496 | ||||||||
| FaxNumber: | 2154134682 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 E DUPONT RD | ||||||||
| Address2: | #7 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604900940 | ||||||||
| FaxNumber: | 2604905063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 06/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | POOL | ||||||||
| AuthorizedOfficialFirstName: | JAYNE | ||||||||
| AuthorizedOfficialMiddleName: | FLECK | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4694678705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 100133720W | 05 | IN | MEDICAID | 000000175000 | 01 | IN | BLUE CROSS BLUE SHEILD | OTHER |