Basic Information
| Provider Information | |||||||||
| NPI: | 1851579601 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICAL THERAPY OF JOPLIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1227 E 32ND ST | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648042811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176247400 | ||||||||
| FaxNumber: | 4176247403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1227 E 32ND ST | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648042811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176247400 | ||||||||
| FaxNumber: | 4176247403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2008 | ||||||||
| LastUpdateDate: | 11/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | PARKER | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4176247400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 114999 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000572905 | 01 | MO | BCBS ANTHEM | OTHER |