Basic Information
Provider Information | |||||||||
NPI: | 1174605687 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HAYMARKET PHYSICAL THERAPY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14535 JOHN MARSHALL HIGHWAY | ||||||||
Address2: | SUITE 203 | ||||||||
City: | GAINESVILLE | ||||||||
State: | VA | ||||||||
PostalCode: | 20155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037530974 | ||||||||
FaxNumber: | 7037539709 | ||||||||
Practice Location | |||||||||
Address1: | 14535 JOHN MARSHALL HIGHWAY | ||||||||
Address2: | SUITE 203 | ||||||||
City: | GAINESVILLE | ||||||||
State: | VA | ||||||||
PostalCode: | 20155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037530974 | ||||||||
FaxNumber: | 7037539709 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SAGLE | ||||||||
AuthorizedOfficialFirstName: | ANGIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN'S ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 7038809856 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
No ID Information.