Basic Information
| Provider Information | |||||||||
| NPI: | 1871669382 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PANTOPS PHYSICAL THERAPY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1490 PANTOPS MOUNTAIN PL | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229114601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4342456472 | ||||||||
| FaxNumber: | 4342456474 | ||||||||
| Practice Location | |||||||||
| Address1: | 1490 PANTOPS MOUNTAIN PL | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229114601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4342456472 | ||||||||
| FaxNumber: | 4342456474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 10/17/2013 | ||||||||
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| AuthorizedOfficialLastName: | COLLINS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4342456472 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | C09575 | 01 | MEDICARE PTAN | OTHER | 010206383 | 05 | VA | MEDICAID |