Basic Information
| Provider Information | |||||||||
| NPI: | 1164790630 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER REHAB MANAGEMENT, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PT SOLUTIONS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 441146 | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301609522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709171395 | ||||||||
| FaxNumber: | 7704233369 | ||||||||
| Practice Location | |||||||||
| Address1: | 249 MACK BAYOU LOOP | ||||||||
| Address2: | STE 101 | ||||||||
| City: | SANTA ROSA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324597198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789323629 | ||||||||
| FaxNumber: | 7704233369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2011 | ||||||||
| LastUpdateDate: | 08/16/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PHILPOT | ||||||||
| AuthorizedOfficialFirstName: | CARMEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 6784033568 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PREMIER REHAB MANAGEMENT, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.