Basic Information
Provider Information | |||||||||
NPI: | 1922020361 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SAPP | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | MELVIN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2 MASHBURN ST 102 | ||||||||
Address2: |   | ||||||||
City: | HAWKINSVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 310364961 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4787834460 | ||||||||
FaxNumber: | 4787834466 | ||||||||
Practice Location | |||||||||
Address1: | 3051 WATSON BLVD 525 | ||||||||
Address2: |   | ||||||||
City: | WARNER ROBINS | ||||||||
State: | GA | ||||||||
PostalCode: | 310938556 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4789534563 | ||||||||
FaxNumber: | 4789534564 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2006 | ||||||||
LastUpdateDate: | 07/22/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4656 | GA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 000754619B | 05 | GA |   | MEDICAID |