Basic Information
| Provider Information | |||||||||
| NPI: | 1619095734 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GATE CITY PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1951 BENCH RD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082372080 | ||||||||
| FaxNumber: | 2082371084 | ||||||||
| Practice Location | |||||||||
| Address1: | 1951 BENCH RD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082372080 | ||||||||
| FaxNumber: | 2082371084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | OTTO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2082372080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | RPT-186 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | T0890 | 01 | ID | BLUE CROSS | OTHER |