Basic Information
| Provider Information | |||||||||
| NPI: | 1528582145 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMORY PHYSICAL THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8259 WICKER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463738878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193656560 | ||||||||
| FaxNumber: | 2193656561 | ||||||||
| Practice Location | |||||||||
| Address1: | 3903 S COBB DR SE STE 275 | ||||||||
| Address2: | |||||||||
| City: | SMYRNA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300808504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042512121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2017 | ||||||||
| LastUpdateDate: | 07/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2193656560 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 5419170001 | 01 | GA | NSC | OTHER | GRP6756 | 01 | GA | MEDICARE PIN | OTHER | DD0145 | 01 | GA | MEDICARE PIN | OTHER |