Basic Information
| Provider Information | |||||||||
| NPI: | 1538250642 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTER FOR PHYSICAL THERAPY & SPORTS REHAB | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 495 GOLD STAR HWY | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | GROTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063406803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604468254 | ||||||||
| FaxNumber: | 8604468293 | ||||||||
| Practice Location | |||||||||
| Address1: | 495 GOLD STAR HWY | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | GROTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063406803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604468254 | ||||||||
| FaxNumber: | 8604468293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PROPFE | ||||||||
| AuthorizedOfficialFirstName: | GERDT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8604468254 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1847 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0V1692 | 01 | CT | HEALTH NET | OTHER | 080001847CT01 | 01 | CT | ANTHEM BLUE CROSS | OTHER |