Basic Information
| Provider Information | |||||||||
| NPI: | 1477923886 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDGEBROOK PHYSICAL THERAPY, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CORA PHYSICAL THERAPY - EDGEBROOK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 SHAWNEE RD | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458053529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192216717 | ||||||||
| FaxNumber: | 4192220507 | ||||||||
| Practice Location | |||||||||
| Address1: | 1643 N ALPINE RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611071462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152896942 | ||||||||
| FaxNumber: | 8155471024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2015 | ||||||||
| LastUpdateDate: | 10/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | ROUSH | ||||||||
| AuthorizedOfficialFirstName: | BRAD | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4192216712 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.