Basic Information
| Provider Information | |||||||||
| NPI: | 1609193911 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST SPORT & SPINE REHABILITATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4420 W JONATHAN MOORE PIKE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472014685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123422411 | ||||||||
| FaxNumber: | 8123422413 | ||||||||
| Practice Location | |||||||||
| Address1: | 4420 W JONATHAN MOORE PIKE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472014685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123422411 | ||||||||
| FaxNumber: | 8123422413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2010 | ||||||||
| LastUpdateDate: | 08/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | HARTWELL | ||||||||
| AuthorizedOfficialFirstName: | DUKE | ||||||||
| AuthorizedOfficialMiddleName: | WADE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8123422411 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT, CERT MDT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 05008884A | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.