Basic Information
| Provider Information | |||||||||
| NPI: | 1639346547 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOSPORT PHYSICAL THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 MATHEWS DR STE D5 | ||||||||
| Address2: | |||||||||
| City: | HILTON HEAD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299263768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436815640 | ||||||||
| FaxNumber: | 8436815631 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 MATHEWS DR STE D5 | ||||||||
| Address2: | |||||||||
| City: | HILTON HEAD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299263768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436815640 | ||||||||
| FaxNumber: | 8436815631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2008 | ||||||||
| LastUpdateDate: | 05/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | FROMDAHL | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8436815640 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7620 | 01 | SC | MEDICARE GROUP NUMBER | OTHER |