Basic Information
| Provider Information | |||||||||
| NPI: | 1770024267 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPRINGFIELD PHYSICAL THERAPY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPRINGFIELD PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 265 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400690265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594819008 | ||||||||
| FaxNumber: | 8594819004 | ||||||||
| Practice Location | |||||||||
| Address1: | 1113B LINCOLN PARK RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400699573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594819008 | ||||||||
| FaxNumber: | 8594819004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2017 | ||||||||
| LastUpdateDate: | 03/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | CONNOR-ISRAEL | ||||||||
| AuthorizedOfficialFirstName: | KAY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8594819008 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7100331760 | 05 | KY | MEDICAID |