Basic Information
| Provider Information | |||||||||
| NPI: | 1881834448 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPORTSMED PHYSICAL THERAPY, INC., P.S. | ||||||||
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| OtherOrganizationName: | SPORTSMED PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11009 | ||||||||
| Address2: | CASCADE BILLING | ||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985081009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603522037 | ||||||||
| FaxNumber: | 3603520637 | ||||||||
| Practice Location | |||||||||
| Address1: | 463 TREMONT STREET W. | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983660000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608951160 | ||||||||
| FaxNumber: | 3608951161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2009 | ||||||||
| LastUpdateDate: | 05/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | KERSHAW | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
| AuthorizedOfficialMiddleName: | BLAKE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER / PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 8014557329 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | P.T., M.P.T., O.C.S | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.