1003032053 NPI number — SUMMIT PHYSICAL THERAPY INC

Table of content: (NPI 1003032053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003032053 NPI number — SUMMIT PHYSICAL THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMIT PHYSICAL THERAPY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003032053
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
414 PENCO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEIRTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26062-3822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-723-3780
Provider Business Mailing Address Fax Number:
304-723-4110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 N CHESTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW CUMBERLAND
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26047-9604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-564-1098
Provider Business Practice Location Address Fax Number:
304-564-5020
Provider Enumeration Date:
04/18/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
304-564-1098

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  001084 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810004835 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: ========= . This is a "TAX ID" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 000745331 . This is a "BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".