Basic Information
| Provider Information | |||||||||
| NPI: | 1316013204 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERACTIVE PHYSICAL THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3405 NW HUNTERS RIDGE TER STE 300 | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666182510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852462300 | ||||||||
| FaxNumber: | 7852462301 | ||||||||
| Practice Location | |||||||||
| Address1: | 4745 NW HUNTERS RIDGE CIR STE D | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666182538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852462300 | ||||||||
| FaxNumber: | 7852462301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 11/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | BAIRD | ||||||||
| AuthorizedOfficialFirstName: | RIC | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7852462300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 11-02038 | KS | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 115585 | 01 | KS | BCBS GROUP NUMBER | OTHER | 100447490A | 05 | KS | MEDICAID |