Basic Information
| Provider Information | |||||||||
| NPI: | 1588690622 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN DELAWARE PHYSICAL THERAPY, INC. | ||||||||
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| OtherOrganizationName: | SDPT, INC. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 SAVANNAH RD | ||||||||
| Address2: | SUITE A-1 | ||||||||
| City: | LEWES | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199581550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026442530 | ||||||||
| FaxNumber: | 3026442556 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 SAVANNAH RD | ||||||||
| Address2: | SUITE A-1 | ||||||||
| City: | LEWES | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199581550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026442530 | ||||||||
| FaxNumber: | 3026442556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 03/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | HALL | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3026442530 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | U1-0000441 | DE | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | 1993106012 | DE | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0000625026 | 05 | DE | MEDICAID |