Basic Information
| Provider Information | |||||||||
| NPI: | 1578586970 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BDM ASSOCIATES LLC | ||||||||
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| OtherOrganizationName: | PEAK PERFORMANCE PHYSICAL THERAPY & SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 BERRYWOOD DR | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734498771 | ||||||||
| FaxNumber: | 5734496563 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 S HENRY CLAY BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ASHLAND | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650109444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736571915 | ||||||||
| FaxNumber: | 5736571875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 06/09/2011 | ||||||||
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| AuthorizedOfficialLastName: | REEDER | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BILLING | ||||||||
| AuthorizedOfficialTelephone: | 5734496082 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BDM ASSOCIATES LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 2255A2300X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 834765000 | 05 | MO | MEDICAID |