Basic Information
| Provider Information | |||||||||
| NPI: | 1164474334 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAY STATE PHYSICAL THERAPY OF RANDOLPH INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BAY STATE PHYSICAL THERAPY OF RANDOLPH PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 703 GRANITE ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | BRAINTREE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021845350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819613370 | ||||||||
| FaxNumber: | 7819611291 | ||||||||
| Practice Location | |||||||||
| Address1: | 703 GRANITE ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | BRAINTREE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021845350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819613370 | ||||||||
| FaxNumber: | 7819611291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WINDWER | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7819613370 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DC/PT | ||||||||
| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 225X00000X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 689511 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 9705601 | 05 | MA | MEDICAID | 626127 | 01 | MA | HARVARD PILGRIM | OTHER | 0009411 | 01 | MA | ALLWAYS HEALTHCARE (FORMERLY NHP) | OTHER | 684486 | 01 | MA | OPTUM/UHC | OTHER | PT0101 | 01 | MA | MEDICARE PIN | OTHER | Y61008 | 01 | MA | BLUE CROSS BLUE SHIELD (MA) | OTHER |