Basic Information
| Provider Information | |||||||||
| NPI: | 1801024385 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH SOUTH PHYSICAL THERAPY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WASHINGTON PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4593 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | ROSLINDALE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021314844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173279097 | ||||||||
| FaxNumber: | 6173274307 | ||||||||
| Practice Location | |||||||||
| Address1: | 4593 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | ROSLINDALE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021314844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173279097 | ||||||||
| FaxNumber: | 6173274307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2009 | ||||||||
| LastUpdateDate: | 06/23/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GAROFALO | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6173279097 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PTA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 122 | MA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251X0800X | 122 | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | Y61200 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 9786082 | 05 | MA | MEDICAID | 0029723 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | 7380356 | 01 | MA | AETNA | OTHER | AA9360 | 01 | MA | HARVARD PILGRIM HEALTH INSURANCE | OTHER |